Wildfires and Public Health: Lessons Learned in Los Angeles County

1. Wildfires and Public Health:Lessons Learned in Los Angeles County Jonathan Fielding, MD, MPH Cyrus Rangan, MD Deborah Davenport, RN, PHN, MS Los Angeles County Department of Public Health January 29, 2008

2. Learning Objectives • Discuss the growing public health importance of wildfires. • List three roles for local public health departments in responding to wildfires. • Describe how the use of a public health emergencymanagement system cansupport wildfire responseefforts. By the end of this presentation, you will be able to: Malibu Fire, Pepperdine University Used with permission of LA County Fire Department

3. Overview • Background • PH Emergency Management System • Surveillance of air quality impacts • Surveillance of adverse health effects • External communications • Addressing sheltering needs • Role of environmental health • Conclusions

4. The risk of wildfires in my jurisdiction is: A. Unchanged recently B. Increasing C. Decreasing D. Minimal

5. Public Health Implications • Profound public health implications • Smoke and ash exposures lead to acute respiratory symptoms, exacerbations of cardiac conditions, and mental health effects. • Affects vulnerable populations: children, seniors, people with chronic diseases such as asthma, emphysema, and heart disease. • Creates major disruptions in services secondary to evacuations: school closures and increased traffic congestion.

6. Environmental Factors Increase Risk • Environmental factors that elevate the risk of wildfires • Drought conditions • Increased residential and commercial development in high-risk areas • Global warming

7. October 2003 Wildfires across Southern California consumed more than 750,000 acres and destroyed 3,640 homes. October 2007 Wildfires again spread across Southern California, burning 500,000 acres from Santa Barbara to the U.S. - Mexico border. History

8. History (cont.) • Totals for LA County, 2007 • 105,000 acres burned. • 60 homes and structures destroyed; another 67 damaged. • Largest LA County blazes • Ranch Fire (Castaic/Piru): ~58,000 acres burned; 1 home and 9 structures destroyed. • Buckweed Fire: ~40,000 acres burned; 63 homes destroyed. Fire started by child playing with matches.

9. History (cont.)

10. Wildfires: Arial View NASA Satellite Image October 24, 2007 View from Santa Clarita Valley Near Magic Mountain October 21, 2007Used with permission of LA County Fire Department

11. Wildfires: Arial View (cont.) NASA Satellite Images October 21, 2007 (3 hours, 15 minutes between images)

12. Public Health Emergency Management System Activation

13. LAC DPH Emergency Management:Activation County EOC 24 hour contact & coordination for PH emergencies DPH Emergency DeskExec. Duty Officer Community HealthServices/Field PHN & PHI Staff Initial notification Health OfficerDirector Public Health Nursing CD Control Primary DPH units that provide initial response to public health emergencies EnvironmentalHealth Services Toxics EPI

14. The EOC is hub for coordinating all emergency incidents in L.A. County. All county departments, as well as other agencies, have liaisons at the EOC to ensure resources are matched to needs, and departments can collaborate to ensure needs are met. DPH desk notifies Dept of Mental Health (DMH) that public health nursesare staffing shelters and collaborate with DMH staff for stress debriefing of shelter residents. LA Co. Fire notifies DPH that new base camps are opening for EHSinspections of food facilities. Los Angeles County Emergency Operations Center (EOC)

15. LAC DPH Emergency Management • After information is provided to immediate response program group, decision is made by director, through the Emergency Desk, to stand up Department Operations Center (DOC). • DOC is the Incident Command System (ICS)-formatted emergency management operations unit, dedicated to managing the incident for Public Health.

16. The DOC County EOC Public Health liaison has desk at the EOC to facilitate DPH resources and information needs. Public Health DOC SPA ECC (Emergency Control Center) Environmental Health ECC SPA ECC • ECCs called into action based on scope of the emergency. • EHS routinely sets up an ECC to manage environmental health emergencies.

17. Advantages of Using EMS/ICS for PH Emergency Management • Use of the Emergency Management System with ICS provides field staff with organized system for: • Incident tracking • Costs of staff and resources for incident response • Clear chain of command and communication among field staff, PH management, and LA County EOC

18. Surveillance of Air Quality Impacts Santa Clarita and Castaic Fires, 2007

19. Air Quality Surveillance Simi Valley Rapid Changes in Air Quality October 21 to October 22, 2007

20. Air Quality Index • SCAQMD estimates air quality impacts of criteria pollutants using the Air Quality Index (AQI) system • AQI 0–50: “Good” • 51–100: “Moderate” • 101–150: “Unhealthy for Sensitive Groups” • 151– 200: “Unhealthy” • 201 or above: “Very Unhealthy”

21. Public Health Alert • TEP initiates a “Public Health Alert” if any one region will have an AQI > 150, or three or more regions will have an AQI >100. • Health alerts may be initiated at discretion of health officer. • Each morning, Alert is revised, based on new information from AQMD.

22. Air Quality Surveillance • Two-way communication established between LADPH and South Coast Air Quality Management District (SCAQMD). • SCAQMD formulates regional A.M. air quality report, based on results from air monitoring stations, field testing, and mathematical models. • LADPH Toxics Epidemiology Program (TEP) reviews air quality reports and smoke advisories issued by SCAQMD.

23. Air Quality Surveillance Concerns • SCAQMD regions based on topography, not population centers. • Lack of published standards to predict health impacts based on these measurements. • Potential to validate our internal judgments based on Syndromic Surveillance data.

24. Air Quality Surveillance Updates • Updated air quality data reviewed throughout day, and preparations made for potential alerts for next day. • Daily communication occurs with Los Angeles Unified School District (LAUSD) and Los Angeles County Office of Education (LACOE) to coordinate outside physical activity messaging. • Local school districts outside of LAUSD and private schools added to distribution list depending on location. • TEP available throughout day for media inquiries about health effects of adverse changes to air quality.

25. Surveillance of Adverse Health Effects Smoke Off Pepperdine Dorms, MalibuUsed with permission of LA County Fire

26. Pre-existing Syndromic Surveillance System • Collects daily chief complaint data from 35 hospital emergency departments (ED). • Reviews and categorizes presenting complaints into syndromes (GI, neuro, rash, respiratory). • Transmits data electronically each day, including weekends. • Tracks syndrome counts over time. • Statistical increase in syndrome counts triggers a signal.

27. Strengths of the Syndromic System • Potential for early detection of major outbreaks or public health events. • Useful in defining location and scope of an outbreak or public health event in near-real time. • Can customize syndromes such as heat-related and asthma syndrome during wildfires. • Detects major trends from baseline patterns, not individual cases.

28. Limitations of Syndromic System • Data includes chief complaints, not diagnosis. • Potential concerns related to sensitivity and specificity.

29. Respiratory Syndrome-Related ED Visits • Overall respiratory-related visits significantly increased during the wildfire. • Generated three consecutive signals from October 22 to October 25.

30. Respiratory Syndrome-Related ED Visits (cont.)

31. Asthma Syndrome-Related ED Visits • Three signals generated during October 21 to 24. • Average asthma syndrome-related daily ED visits changed from 69 in week before fires began to 87 during week after fires began (p=0.0115).

32. Asthma Syndrome-Related ED Visits (cont.)

33. External Communications

34. Public Information Officers (PIO) • One PIO stationed at Public Health Department Operations Center at all times. • One PIO stationed at County Emergency Operations Center for 36 hours. • Coordinated with TEP to develop air quality alerts; distributed to internal and external audiences. • Participated in daily conference calls with state Emergency Operations Management communication team and other affected county PIOs.

35. Health Alerts • Health alert listserv established. • Health alerts posted on County and Department of Public Health Web sites. • Health alerts sent to: • School districts and private schools • 211: LA the County’s information and referral line • 311: LA City’s information line • Board of Supervisor offices and other county departments (Dept of Health Services; Parks and Recreation) • California National Guard

36. Other External Communication Activities • Press releases/fact sheets on wildfire smoke and safe ash clean-up created in English and Spanish. • Public service announcement, created by CDC on safe ash clean-up, disseminated to local radio stations. Ran on 13 AM and FM stations (news radio and music format). • Participated in hot wash call sharing lessons learned from state OES and other impacted counties. • Emergency management personnel from CDC and other CA county PIOs listened in as observers.

37. Addressing Sheltering Needs Structural Fire, Santa Clarita, Used with permission of LA County Fire

38. Public Health Nurse (PHN) Disaster Response Roles • Disease surveillance and control • Health education • Mass prophylaxis • Surge capacity for mass care shelters

39. Shelter Nursing: Role of PHN • Shelter surveillance. • MOU: Back-up American Red Cross (ARC) staffing for shelter nursing. • PHNs receive ARC training and certification. • Localized incidents provide experience in planning for mass care shelters.

40. Staffing Shelters and FEMA Local Assistance Centers • Two shelters opened in Santa Clarita. • Saugus HS: Approx. 140 sheltered the first night. • Golden Valley HS: Approx. 100-125 residents for two days; 100 residents from a local independent living center and personal caregivers. • 2 PHNs and 1 DMH Counselor for each shelter, 24 hours/day. • No syndromic patterns, only personal health issues such as diabetic management supplies for a resident and stress-related issues. • 3 FEMA Local Assistance Centers opened and staffed with PHNs providing resources and referrals for residents for approx. one week, 12 hours/day.

41. Lessons Learned in Shelter Nursing • Develop ongoing standby assignments for PHN off-duty response to public health emergencies. • Standardize emergency staffing procedures/call-down lists. • Prepare packaged health education and resource/referral lists for disaster assistance centers. • Ensure that all PHNs receive training/retraining for mental health debriefing of disaster victims. • Develop protocols for managing special needs shelters.

42. Role of Environmental Health

43. Fire Camps • Problem • How to ensure health and safety of first responders? • Inspections prevent sickness and spread of disease. • Action • Food, water, and waste issues evaluated. • Daily inspections conducted. • No’ problems encountered. Photo: LA Co. DPH Environmental Health Services

44. Food Facilities • Problem • Fire damage and no power. • Action • 114 food facilities assessed. • 103 with no problems • 2 had exterior fire damage • 1 closed for a rodent infestation • 1 out of business • 7 not in operation • Fire recovery guidance documents issued.

45. Housing • Problem • Fire damage and accumulation of trash and debris in multiple family dwellings with 5 or more units. • Action • 113 housing facilities assessed. • 95 with no problems • 2 destroyed by fire • 2 with no power • 5 with an accumulation of trash and debris • 9 unable to be inspected • Fire recovery guidance documents issued.

46. Vector Populations • Problem • Increased vector population and migrating rodents can spread diseases. • Mosquitoes breed in standing water and unattended swimming pools. • Rodents infest homes and businesses seeking food and shelter. • Action • Local mosquito and vector control districts notified to identify, control, and prevent mosquito breeding. • Surveillance conducted. • Complaint tracking and bait dissemination occurred. • Identified 10 single family dwellings with pools. • Two contained green water.

47. Solid Waste • Problem • Large amounts of burned debris shorten the life and compromise the integrity of landfills. • Sorting and recycling extends the life. • Exclusion of hazardous materials ensures integrity. • Action • Created partnerships with CAL/EPA, Integrated Waste Management Board and LAC Public Works, HazMat, and Sanitation District. • Created agreements that hazardous materials would be separated at burn sites and debris disposed at Calabasas landfill. • Requests granted for landfills to extend operation hours and exceed daily tonnage.

48. Conclusions

49. Conclusions • By early activation of emergency management system, department can operate as unified response agency. • Reach-back capability is important for deployed personnel. • Need more communications staff to serve as PIOs. • Need a toll-free number for air quality information. • Need to validate criteria for issuing health alerts.

50. Primary Prevention Strategies • Recommend use of more fire-resistant landscaping. • Encourage homeowners and developers to establish defensible spaces around homes. • Establish collaboration between public health and fire and planning agencies to help improve community education on wildfire prevention.