Wildfires and Public Health: Lessons Learned in Los Angeles County
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. Learning Objectives. Discuss the growing public health importance of wildfires. - PowerPoint PPT Presentation
Wildfires and Public Health:Lessons Learned in Los Angeles CountyJonathan Fielding, MD, MPHCyrus Rangan, MDDeborah Davenport, RN, PHN, MSLos Angeles County Department of Public HealthJanuary 29, 2008Learning ObjectivesDiscuss 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 emergency management system can support wildfire response efforts.By the end of this presentation, you will be able to:Malibu Fire, Pepperdine University Used with permission of LA County Fire DepartmentOverviewBackground PH Emergency Management SystemSurveillance of air quality impacts Surveillance of adverse health effects External communicationsAddressing sheltering needsRole of environmental health ConclusionsThe risk of wildfires in my jurisdiction is: A. Unchanged recentlyB. IncreasingC. DecreasingD. MinimalPublic Health ImplicationsProfound public health implicationsSmoke 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.Environmental Factors Increase RiskEnvironmental factors that elevate the risk of wildfiresDrought conditionsIncreased residential and commercial development in high-risk areasGlobal warmingHistoryOctober 2003 Wildfires across Southern California consumed more than 750,000 acres and destroyed 3,640 homes.October 2007Wildfires again spread across Southern California, burning 500,000 acres from Santa Barbara to the U.S. - Mexico border.History (cont.)Totals for LA County, 2007105,000 acres burned.60 homes and structures destroyed; another 67 damaged.Largest LA County blazesRanch 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.History (cont.)Fire NameAcresProperties Damaged and DestroyedProperties ThreatenedEvacuatedFire FightersCanyon Fire4,5002290021,0002,750October Fire35084Magic Fire2,82400Ranch Fire58,40112600Buckweed Fire38,3569359,000Wildfires: Arial ViewNASA Satellite ImageOctober 24, 2007View from Santa Clarita Valley Near Magic MountainOctober 21, 2007 Used with permission of LA County Fire DepartmentWildfires: Arial View (cont.)NASA Satellite ImagesOctober 21, 2007(3 hours, 15 minutes between images)Public Health Emergency Management System ActivationLAC DPH Emergency Management:Activation24 hour contact & coordination for PH emergenciesCounty EOCDPH Emergency Desk Exec. Duty OfficerHealth Officer DirectorCommunity Health Services/FieldPHN & PHI StaffPublic Health NursingCD ControlEnvironmental Health ServicesToxics EPIInitial notificationPrimary DPH units that provide initial response to public health emergenciesLos Angeles County Emergency Operations Center (EOC)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 nurses are 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 EHS inspections of food facilities.LAC DPH Emergency ManagementAfter 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.The DOCECCs called into action based on scope of the emergency.EHS routinely sets up an ECC to manage environmental health emergencies.Public Health liaison has desk at the EOC to facilitate DPH resources and information needs.County EOCPublic Health DOCSPA ECC (Emergency Control Center)Environmental Health ECCSPA ECCAdvantages of Using EMS/ICS for PH Emergency ManagementUse of the Emergency Management System with ICS provides field staff with organized system for:Incident trackingCosts of staff and resources for incident responseClear chain of command and communication among field staff, PH management, and LA County EOCSurveillance of Air Quality ImpactsSanta Clarita and Castaic Fires, 2007Air Quality SurveillanceSimi ValleyRapid Changes in Air QualityOctober 21 to October 22, 2007Air Quality IndexSCAQMD estimates air quality impacts of criteria pollutants using the Air Quality Index (AQI) systemAQI 050: Good51100: Moderate101150: Unhealthy for Sensitive Groups151 200: Unhealthy201 or above: Very UnhealthyPublic Health AlertTEP 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.Air Quality SurveillanceTwo-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.Air Quality Surveillance ConcernsSCAQMD 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.Air Quality Surveillance UpdatesUpdated 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.Surveillance of Adverse Health EffectsSmoke Off Pepperdine Dorms, Malibu Used with permission of LA County FirePre-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.Strengths of the Syndromic SystemPotential 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.Limitations of Syndromic SystemData includes chief complaints, not diagnosis.Potential concerns related to sensitivity and specificity.Respiratory Syndrome-Related ED VisitsOverall respiratory-related visits significantly increased during the wildfire. Generated three consecutive signals from October 22 to October 25.Respiratory Syndrome-Related ED Visits (cont.)Asthma Syndrome-Related ED VisitsThree 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).Asthma Syndrome-Related ED Visits (cont.)External CommunicationsPublic 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.Health AlertsHealth alert listserv established.Health alerts posted on County and Department of Public Health Web sites.Health alerts sent to:School districts and private schools211: LA the Countys information and referral line311: LA Citys information lineBoard of Supervisor offices and other county departments (Dept of Health Services; Parks and Recreation)California National GuardOther External Communication ActivitiesPress 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.Addressing Sheltering NeedsStructural Fire, Santa Clarita, Used with permission of LA County FirePublic Health Nurse (PHN) Disaster Response RolesDisease surveillance and controlHealth educationMass prophylaxisSurge capacity for mass care sheltersShelter Nursing: Role of PHNShelter 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.Staffing Shelters and FEMA Local Assistance CentersTwo 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. Lessons Learned in Shelter NursingDevelop 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.Role of Environmental Health Fire CampsProblem How to ensure health and safety of first responders? Inspections prevent sickness and spread of disease.ActionFood, water, and waste issues evaluated.Daily inspections conducted. No problems encountered.Photo: LA Co. DPH Environmental Health ServicesFood FacilitiesProblemFire damage and no power. Action114 food facilities assessed.103 with no problems2 had exterior fire damage1 closed for a rodent infestation1 out of business7 not in operation Fire recovery guidance documents issued.HousingProblem Fire damage and accumulation of trash and debris in multiple family dwellings with 5 or more units.Action113 housing facilities assessed. 95 with no problems2 destroyed by fire2 with no power5 with an accumulation of trash and debris9 unable to be inspectedFire recovery guidance documents issued.Vector PopulationsProblem 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.ActionLocal 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.Solid WasteProblem 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.ActionCreated 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. Conclusions ConclusionsBy 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.Primary Prevention StrategiesRecommend 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. The Ranch Fire (or Castaic Fire) burned along the Los Angeles-Ventura county line, in the Angeles and Los Padres national forests.The Buckweed Fire burned north of Santa Clarita in Agua Dulce and the community of Canyon Country, triggering many evacuations. This fire was the result of a child playing with matches.Local picture from Santa Clarita ValleyNASA image of the 2007 SoCal FiresThese satellite images were taken by NASA just THREE hours apart, The key to LACDPH emergency managements is the 24 hour Emergency Desk. The Desk provides information to key units with DPH regarding emerging issues that might lead to a public health emergency response. The Executive Duty Officer, a position rotated among DPH executive staff, determines the level of response and authorizes deployment of forces and functions as the on-call Incident Manager .While Public Health begins gathering resources to address possible needs for the wildfires, the Countys EOC opens to direct all resources related to the fires. All departments work together to assure resources are readily available to address all aspects of the emergency incident. A good example is the collaboration at the EOC level between DPH and Mental Health. The department reps or liaisons work closely together to address issues identified at the shelters. This collaboration filters down to the field level where local PHNs staffing the shelter are notified of DMH staff assignments and work on stress debriefing of shelter residents together.Once the issues regarding an emergency incident are made known to the first responder public health units, a determination is made for the levels of activation for response. If the Department Operations Center is opened, it is done so using ICS format and reports up through the County Emergency Operations Center (EOC)A key DPH role is that of Liaison at the Public Health Desk at the EOC. This position tracks public health issues and needs and communicates closely with the DOC. Based on the scope of the event, another level of activation is at the program unit level. In the case of the wildfires, or in any emergency requiring intervention from our Environmental Health Services program, as Emergency Control Center for that program is set up. It also operates in an ICS structure and reports to the department while managing its roles and personnel. A similar organization could occur in the Service Planning Areas (SPAs) in the event of a widespread disaster such as an earthquake.Bullet 1- Get feedback from CHS regarding specificsFor Good or Moderate conditions, no special health recommendations are givenUnhealthy for Sensitive Groups: Susceptible persons (such as those with heart or lung disease) should minimize outdoor activityUnhealthy: Everyone should discontinue prolonged outdoor exercise lasting more than 1 hour, Sensitive persons should avoid outdoor activity altogetherVery Unhealthy: Everyone should discontinue any vigorous outdoor activity regardless of durationCUSUM (cumulative sum) signal is 3 standard deviations above the 7 day average CUSUM (cumulative sum) signal is 3 standard deviations above the 7 day average The four roles are those as identified for PHNs in Los Angeles County. We realize that smaller Local Health Departments may only have capacity to provide one or two of these roles, however, the skills in carrying them out are useful even as a resource/ reference, and can help local public health nursing plan for additional mutual aid for disasters. For disease surveillance and control: DPH has specific surveillance teams, but in the event of widespread disaster, PHNs in the field will be called upon to participate in conducting surveillance, investigation and control strategies.Health Education: we have developed a Speakers Bureau approach that packages topics such as disaster recovery, a variety of communicable disease topics, such as Pandemic Flu, West Nile Virus and smallpox, to use both as preparation for and in the aftermath of a disaster. PHNs are trained to do these presentations and have an identified map of contact groups and forums to do such presentations in the community.Mass Prophylaxis: In the last three years we have conducted major exercises that not only test our capacity to provide mass prophy, but also to carry this out using Incident Command structures in partnership with local governments, the FBI, the military, and private industry. Mass Care Shelters: In recent years ARC has not had enough nurses to staff potential shelter sites throughout the county. DPH has an MOU with EMS and ARC to provide nursing staff for shelters and special care needs shelters. This is a project still in development as we determine the best level of nursing to provide in such instances. For isolated events such as the fires we staff routinely with our Public Health Nurses for the duration of the shelters operation and also provide general oversite for any possible threats to the health of shelter clients or staff at the site.When any ARC shelters are opened, the Service Planning Area PHNs regularly conduct shelter surveillance using a form developed by Nursing Administration to determine if any potential communicable disease issues or other health risks exist in the shelter and work with shelter staff to resolve them. In recent years, L.A. County Public Health and the Department of Health Services, have developed an MOU with the local American Red Cross chapter to provide any necessary shelter nurses, a need that is increasing as the number of ARC nurse volunteers has sharply declined. Nursing Administration collaborates with ARC to provide Shelter Nursing training and certification for all DPH PHNs.The combination of shelter surveillance and actual shelter staffing in more local incidents such as the wildfires provides Public Health Nurses with the experience to plan for large mass care shelters for pandemic flu, earthquakes, and other broad disaster events.The shelters were opened for approximately two days. The third identified shelter was to be in Agoura, near Malibu. But it determined that Malibu evacuees moved to alternative housing, including hotels in Santa Monica, or with other family or friends. In Santa Clarita, a local independent living center in the area lost water and power due to the fires nearby and needed to evacuate. Fortunately, they presented with their regular caregiver staff from the facility, so their shelter management needs were manageable. But it certainly caused us pause to consider what we would have done, had not the caregivers been able to get through the perimeter to the shelter.The FEMA centers basically provided local resources and recovery information for local residents impacted by the fire.We are constantly improving and learning about new ways to enhance our ability to conduct emergency staffing. After doing the staffing for this incident we have decided to plan and implement an ongoing standby status assignment for all public health nursing staff. This will entail consultation with Human Resources as well as employee unions and entail some additional costs for standby pay and equipment such as phones or radios, but will provide the ready status that DPH will need to respond quickly to any type of public health disaster situation. For shelter nursing training, DPH has arranged with ARC to conduct train-the-trainer sessions for DPH PHNs as ARC does not have the resources to assure that all of our nurses have this training.We also recently began training our PHNs for mental health debriefing. We find that this skill is critical for PHNs in the field, whether it is in a shelter situation or in a disease investigation as they are able to help residents deal with the anxiety and stress of the disaster event and begin moving towards recovery.In staffing a shelter in Santa Clarita, we encountered about 100 residents moved from an independent living facility in the area. While each of the residents had their own personal caregivers present in the shelter, the issue of developing protocols for Special Needs Shelters became very clear, particularly now that ARC has said they do not have the capacity to operate these types of shelters. The issues of staffing, equipment and shelter management, particularly in the early hours after evacuation of dependent care facilities, are ones we are now looking at, using lessons learned from Katrina special sheltering, nursing home evacuation sheltering conducted by San Diego County and Orange County during their wildfires. Bullet 1- Efforts are singular and the entire department can be responsive to requests for support.Bullet 2- Without this capability personnel are reliant on one or two people to coordinate with Bullet 3- EH personnel can provide a more active service by managing and receiving information from their field personnel. Issues that will have a County-wide impact are still managed at the department level, but the ECC has greater flexibility to manage tactical issues.