Incident Response: Occupational and Environmental Health

1. Incident Response:Occupational and Environmental Health Working Together for All Hazards Readiness San Joaquin County August 20, 2008 Division of Environmental and Occupational Disease Control California Department of Public Health Celia Golden, MD, MPH celia.golden@cdph.ca.gov Slides created by Rupali Das, MD, MPH

2. Division of Environmental and Occupational Disease Control (DEODC) • Environmental Health Investigation • Occupational Health • Environmental Health Laboratory • Childhood Lead Poisoning Prevention

3. What DEODC Provides • Technical advice and expertise in: • Assessing chemical exposure • Exposure levels and anticipated risks • Health investigation and Illness tracking • Laboratory monitoring • Methods to minimize human health effects • Risk communication and education • Community • Workers • 24-hour on call duty officer • 1-800-971-9631 (contact through CDPH duty officer)

4. Occupational Health BranchPromoting Healthy Workplaces • Provides guidance in protecting workers who respond to biologic and chemical incidents • Tracks conditions such as work-related asthma to direct prevention efforts at high-risk jobs • Investigates selected work-related illness incidents • Promotes alternatives that are safe for human and environmental health

5. Environmental Health Investigations Branch Protecting the Health of Californians • Assesses the association between health and the environment • Collaborates with communities to address environmental health concerns • Collaborates with other agencies, states to share preparedness knowledge • Interstate Chemical Terrorism Workgroup

6. The Role of Public Health following a chemical incident • Identify the agent or cause based on • Clinical presentation • Lab analysis of • environmental samples or • biological specimens • Determine temporal and geographical distribution of exposure • Determine relative (high/low) exposures

7. The Role of Public Health following a chemical incident (cont.) • Predict expected health outcomes • Based on agent, exposure dose • Provide advice for treatment and evaluation, immediate and long-term • Provide epidemiologic follow-up to document long-term effects • Prevent further adverse effects

9. Population Injured in Chemical Incidents Based on 4,425 victims reported to ATSDR’s HSEES, 1999-2000

10. Workers Inadequately Prepared • Firefighters feel prepared but may not be aware of chronic health effects • Patrol officers feel least prepared even though they may be first to arrive the scene of an incident

11. Response Workers are Varied • Law enforcement • EMT, fire fighters • Health care providers • Public health agencies • Cleanup, remediation, construction

12. …and so are Hazards • Chemical • Thermal • Infectious • Mechanical • Ergonomic • Mental stress

13. Chemicals Detected at WTC SiteSampled 9/13/01—1/11/02 % above OSHA Standard Acid gases 1.6 Asbestos 12.6/0* Carbon monoxide 0.02 Metals 5.1 Noise 35.6 Respirable silica 6.9 Total dust 2.8 Polynuclear aromatic 7.3 hydrocarbons Other substances detected: benzene, dioxin, Freon, mercury Photo: The New Yorker, May 20, 2002 *Final analysis used TEM http://www.osha.gov/nyc-disaster/summary.html

14. Injury Pattern Among Rescue Workers at WTC Site †During first 2 weeks at WTC site, 19% of firefighters reported not using a respirator; 50% reported using a respirator but only rarely. MMWR September 11, 2002; 51:1-20.

15. Long-term Effects of WTC incident • NYFD 1-year follow-up • Decreased lung function equal to 12 years of aging-related decline • Increased symptoms of cough, wheeze, airway reactivity in response workers, residents • 2-fold increase in infants small-for-gestational- age • Depression, PTSD

16. Sulfuric Acid Release • Tank car valve rupture during illegal unloading • 8 tons “oleum”* released over 4 hours • 15-mile long plume • Affected community-- population 110,000 *Oleum= sulfur trioxide (SO3) or (concentrated sulfuric acid H2SO4)

17. Sulfuric Acid ReleaseHealth Outcomes • 22,000 total visits to clinics and emergency rooms • 5000 visits on first day • 95% “worried well” • <5% seen by physician • 90% respiratory • 10% GI • <1% eye Richmond CA, 1991

18. Metam Sodium SpillSacramento River, July 1991 Liquid metam + water  MITC in air, water

19. Emergency Room Visits Days 1-4 • Nausea 51% • Headache 44% • Eye irritation 40% • Throat irritation 26% • Dizziness 23% • Vomiting 22% • Shortness of breath 21% • Chest tightness 16% • Abdominal pain 14% • Cough 10% • Diarrhea 10% Cal/EPA data, 1991

20. Persistent Health Effects • 9 months after the spill, of 197 residents • 10 had worsening of pre-existing asthma • 20 had new onset asthma • Reactive Airways Dysfunction Syndrome Cone J et al. Chest. 1994; 106:500-508.

21. Optimizing Public Health Responseto Chemical Incidents: Workers • Anticipate work-specific hazards and potential emergency response actions • Establish worker health and safety protocols • Illness and Injury Prevention Programs* • Train workers through exercises • Establish communication *Title 8 Sec 3203

22. Optimizing Public Health Responseto Chemical Incidents: Community • Establish criteria for determining illness • Anticipate large numbers of “worried well” • Collect biologic and environmental samples early in the incident • Recognize potential for prolonged effects • Encourage community and personal emergency preparedness plans

23. Public Health Response Tools • California Poison Control System • Rapid Response Registry • Survey Modules

24. Illness after eating watermelonPublic Health Response • Aldicarb highly toxic, unregistered pesticide • Poison Control Centers helped to notify physicians through Emergency Departments • Watermelons embargoed statewide, destroyed • 1000 probable pesticide illness reports • In 8 other states, 2 Canadian provinces • Integrated food surveillance program now operational Goldman. Pesticide food poisoning from contaminated watermelons in California, 1985. ARCHIVES OF ENVIRONMENTAL HEALTH,  July-August, 1990

25. Public Health Response ToolsCalifornia Poison Control System • Calls routed to 4 hotlines • UC Davis Medical Center (Sacramento) • San Francisco General Hospital (San Francisco) • Children's Hospital Central CA (Fresno/Madera) • UC San Diego Medical Center (San Diego) http://www.calpoison.org/ 1-800-222-1222

26. How can Poison Control Centers Serve Public Health Today? • Provide individual treatment advice • Tracking illness patterns to identify surreptitious incidents before they become large scale emergencies

27. Alert Clinician Network • Guidelines for staff to identify a potentially serious public health incident from thousands of calls • Suspicious cases tagged • Low– no action • High– notification of CDPH, follow-up

28. Alert Clinician NetworkTypes of Cases • Food contamination, deliberate/accidental • Contaminated lot of commercial product applied to skin or sprayed in air • Adverse reaction to new product • Environmental contamination of building, public area, transportation system

29. Public Health Response ToolsRapid Response Registry • Tool to track individuals during incidents • Developed during Katrina response by ATSDR • 2-page survey form • Will be accessible on CAHAN during incident

30. Public Health Response ToolsSurvey Modules • Tools for health effects follow-up studies • Environmental exposure module • Occupational module • Lab specimen information • Data collection • Local • Data entry, analysis • State/Local

33. Conclusion • Workers likely to be involved in every incident: varied hazards, injuries • Employers are required to consider potential hazards & prevention methods • Public health agencies investigate causes of illness, provide treatment & follow-up advice • Cooperation essential • inter-agency, inter-jurisdictional • Tools for occupational and environmental evaluation are available

34. Tools for Worker Health & Safety • Guide to Developing your Workplace Injury and Illness Prevention Program • http://www.dir.ca.gov/dosh/dosh_publications/iipp.html • OSHA avian flu guidelines • http://www.osha.gov/OshDoc/data_AvianFlu/avian_flu_guidance_english.pdf • Incident response worker health and safety • http://www.osha.gov/SLTC/emergencypreparedness/nrp_work_sh_annex.html • Hazwoper regulations • www.dir.ca.gov/Title8/5192.html

35. Worker Protection for Avian Flu Cal/OSHA Interim Guidelines • Minimum recommendations for workers who may be exposed to birds with zoonotic avian influenza • Varies by activity and exposure risk • Respiratory, Eye, Hand protection • Disposable coveralls • Boots http://www.dir.ca.gov/dosh/doshreg/AIPPE_matrix_DoshReg.pdf