Beth Resnick

Potential for Chemical Mixture Exposures and Health Risks in New Orleans Post–Hurricane Katrina

ABSTRACT Toxic chemical exposure following Hurricane Katrina was a major concern given the industrial base of the New Orleans area. We evaluated the potential for chemical mixture exposures in the USEPAs hurricane response sampling in Orleans Parish and identified health effects of concern for mixtures observed. Environmental sampling (excluding hazardous waste sites and spills) yielded 165 floodwater sampling locations, 206 soil sampling locations, and 451 sediment sampling locations. Frequently reported chemicals included manufacturing intermediates, metallic elements, and polycyclic aromatic hydrocarbons. Health effects associated with chemicals frequently reported included: blood effects, cancer, cardiovascular, gastrointestinal, kidney, liver and neurological effects. Effect-specific mixtures of two or more chemicals were found at many sampling locations. For example, two carcinogens frequently reported in soil were found together at 64 (31%) soil sample locations; seven nephrotoxicants were found together at 112 (25%) sediment sample locations; three neurotoxic chemicals were found together in 230 (51%) sediment sample locations. Hurricane response sampling showed effect-specific chemical mixtures at many locations indicating opportunity for mixture exposures. Chemicals found together are not unique to New Orleans or to post-hurricane conditions. The results highlight the limitations of single substance risk assessments and have important implications for disaster preparedness and response and surveillance.

The Impact of Local Environmental Health Capacity on Foodborne Illness Morbidity in Maryland

OBJECTIVES We evaluated the relationship between local food protection capacity and service provision in Marylands 24 local food protection programs (FPPs) and incidence of foodborne illness at the county level. METHODS We conducted regression analyses to determine the relationship between foodborne illness and local FPP characteristics. We used the Centers for Disease Control and Preventions FoodNet and Maryland Department of Health and Mental Hygiene outbreak data set, along with data on Marylands local FPP capacity (workforce size and experience levels, budget) and service provision (food service facility inspections, public notification programs). RESULTS Counties with higher capacity, such as larger workforce, higher budget, and greater employee experience, had fewer foodborne illnesses. Counties with better performance and county-level regulations, such as high food service facility inspection rates and requiring certified food manager programs, respectively, had lower rates of illness. CONCLUSIONS Counties with strong local food protection capacity and services can protect the public from foodborne illness. Research on public health services can enhance our understanding of the food protection infrastructure, and the effectiveness of food protection programs in preventing foodborne illness.

Effective Environmental Public Health Surveillance Programs: A Framework for Identifying and Evaluating Data Resources and Indicators

The complexity and multidisciplinary nature of environmental public health (EPH) surveillance call for a systematic framework and a concrete set of criteria to guide development, selection, and evaluation of environmental public health indicators. Environmental public health indicators are the foundation of a comprehensive EPH surveillance system, providing quantitative summary measures and descriptive information about spatial and temporal trends of hazard, exposure, and health effects over person, place, and time. A case-synthesis review of environmental regulatory and public health indicator models was employed to develop a framework and outline a methodological approach to EPH surveillance system development, including the selection of content areas and the corresponding data and environmental public health indicators. The framework is organized around three assessment phases: (1) scientific basis and relevance, (2) analytic soundness, and (3) feasibility, interpretation and utility. By outlining a process and identifying important constructs and criteria, the framework provides practitioners with an effective and systematic tool for making scientifically valid programmatic decisions about EPH content development. Improved decision making ensures more effective EPH surveillance systems and enhanced opportunities to understand and protect the public health from environmental threats.

Advancing health and environmental disease tracking: a 5-year follow-up study

OBJECTIVES Our goal was to gain an understanding of the extent to which environmental public health tracking (EPHT) has progressed since the release of the 2000 Pew Environmental Health Commission report examining the nations EPHT infrastructure. METHODS As a follow-up to the Pew Commission report, we conducted a telephone survey of state practitioners in an effort to assess EPHT trends and changes in state-level capacities and activities over the past several years. RESULTS We found that new and enhanced federal-state partnerships; improved surveillance, data analysis, and communication capacities; and enhanced support of tracking personnel have provided a foundation for progress in the area of EPHT. Also, the Centers for Disease Control and Preventions support of EPHT has strengthened the national environmental public health infrastructure and capacity to track environmental hazards, exposures, and health. CONCLUSIONS Improved funding, data access, and translation of data to prevention activities are critical to sustaining progress in EPHT and developing the evidence base necessary for assessing the longer-term impacts and efficacy of EPHT and related environmental health improvements.

Budgetary decision making during times of scarcity.

Public health is often defined by the sciences on which it is based (eg, epidemiology, tropical medicine, biostatistics) or the programs a health department operates. Far too often the critical role of the health official in garnering political support, financial resources, and public support is not recognized when defining the scope of our system. Because most state health officials are political appointees, their work is sometimes considered to be separate from public health, as if politics and public health were distinct. But the state health official’s interface with the political system and with the state budget office is critical to all aspects of public health. Without political support from the governor and financial support from the legislature, the public health agency cannot effectively protect and improve the health of the population. As is reported at some length in this issue and the March issue of this journal, state and local health departments have seen major budget reductions over the past several years. However, to date there has not been much information regarding the context and decision-making processes around these budget cuts. This column presents select initial findings from a collaborative study with the Johns Hopkins Bloomberg School of Public Health that seeks to provide context and deeper understanding around issues of budgetand priority-setting processes, introduces components of a framework for budgetary decision making identified at the December 2011 ASTHO (Association of State and Territorial Health Officials) Winter Meeting, and links these ideas to the recently released Institute of Medicine (IOM) report For the Public’s Health: Investing in a Healthier Future. The Johns Hopkins-ASTHO study consisted of both qualitative and quantitative research: semistruc-

An examination of the growing US undergraduate public health movement

ObjectivesWith over 10,900 public health bachelor’s degree graduates conferred in 2015, public health undergraduate education in the USA has become mainstream. However, with the recent establishment of a majority of the programs, the impact of the undergraduate programs remains largely unknown. This study examines a sample of undergraduate programs in public health to further elucidate the undergraduate landscape.MethodsSemi-structured interviews and a review of program websites from a sample of 39 institutions across the USA with undergraduate majors labeled as public health were conducted in 2015 to examine program content and operations.ResultsFindings from the 39 programs reviewed demonstrated growing and diverse undergraduate public health programs rapidly evolving. While program enrollments, infrastructure, and curriculum varied among the individual programs, collectively, findings indicated increasing numbers of undergraduate students gaining knowledge and experience in matters related to the health of societies locally, nationally, and globally.ConclusionsStudy findings suggest it is an opportune time for the field to offer guidance, support, and vision to these burgeoning undergraduate programs. Such engagement offers opportunities to advance the programs as well as increase the number of students attuned to societal health in whatever life roles they assume.

Decision Processes and Determinants of Hospital Evacuation and Shelter-in-Place During Hurricane Sandy.

Context: Evacuation and shelter-in-place decision making for hospitals is complex, and existing literature contains little information about how these decisions are made in practice. Objective: To describe decision-making processes and identify determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. Design: Semistructured interviews were conducted from March 2014 to February 2015 with key informants who had authority and responsibility for evacuation and shelter-in-place decisions for hospitals during Hurricane Sandy in 2012. Interviews were recorded, transcribed, and thematically analyzed. Setting and Participants: Interviewees included hospital executives and state and local public health, emergency management, and emergency medical service officials from Delaware, Maryland, New Jersey, and New York. Main Outcome Measure(s): Interviewees identified decision processes and determinants of acute care hospital evacuation and shelter-in-place during Hurricane Sandy. Results: We interviewed 42 individuals from 32 organizations. Decisions makers reported relying on their instincts rather than employing guides or tools to make evacuation and shelter-in-place decisions during Hurricane Sandy. Risk to patient health from evacuation, prior experience, cost, and ability to maintain continuity of operations were the most influential factors in decision making. Flooding and utility outages, which were predicted to or actually impacted continuity of operations, were the primary determinants of evacuation. Conclusion: Evacuation and shelter-in-place decision making for hospitals can be improved by ensuring hospital emergency plans address flooding and include explicit thresholds that, if exceeded, would trigger evacuation. Comparative risk assessments that inform decision making would be enhanced by improved collection, analysis, and communication of data on morbidity and mortality associated with evacuation versus sheltering-in-place of hospitals. In addition, administrators and public officials can improve their preparedness to make evacuation and shelter-in-place decisions by practicing the use of decision-making tools during training and exercises.

Legal Preparedness for Hurricane Sandy: Authority to Order Hospital Evacuation or Shelter-in-Place in the Mid-Atlantic Region

Hospitals were once thought to be places of refuge during catastrophic hurricanes, but recent disasters such as Hurricanes Katrina and Sandy have demonstrated that some hospitals are unable to ensure the safety of patients and staff and the continuity of medical care at key times. The government has a duty to safeguard public health and a responsibility to ensure that appropriate protective action is taken when disasters threaten or impair the ability of hospitals to sustain essential services. The law can enable the government to fulfill this duty by providing necessary authority to order preventive or reactive responses--such as ordering evacuation of or sheltering-in-place in hospitals--when safety is imperiled. We systematically identified and analyzed state emergency preparedness laws that could have affected evacuation of and sheltering-in-place in hospitals in order to characterize the public health legal preparedness of 4 states (Delaware, Maryland, New Jersey, and New York) in the mid-Atlantic region during Hurricane Sandy in 2012. At that time, none of these 4 states had enacted statutes or regulations explicitly granting the government the authority to order hospitals to shelter-in-place. Whereas all 4 states had enacted laws explicitly enabling the government to order evacuation, the nature of this authority and the individuals empowered to execute it varied. We present empirical analyses intended to enhance public health legal preparedness and ensure these states and others are better able to respond to future natural disasters, which are predicted to be more severe and frequent as a result of climate change, as well as other hazards. States can further improve their readiness for catastrophic disasters by ensuring explicit statutory authority to order evacuation and to order sheltering-in-place, particularly of hospitals, where it does not currently exist.

Examining the front lines of local environmental public health practice: a Maryland case study.

OBJECTIVE Local environmental public health (EPH) is the foundation of a nations environmental protection infrastructure. With increasing pressure to demonstrate the ability of EPH activities to effectively protect health, the Johns Hopkins Center for Excellence in EPH Practice, as part of the Centers for Disease Control and Preventions (CDCs) EPH capacity-building effort, developed the Profile of Maryland Environmental Public Health Practice. This profile offers an examination of front-line local EPH strengths, needs, challenges, and provides recommendations to strengthen the EPH infrastructure. METHODS A multistep process was conducted, including site visits to all of Marylands 24 local EPH agencies and a questionnaire addressing administrative structure, communication, funding, workforce, crisis management, technology, and legal authority, completed by local EPH directors. RESULTS The Maryland Profile revealed a dedicated and responsive workforce limited by a neglected, fragmented, and underfunded EPH infrastructure. Recommendations regarding leadership, workforce, training, technology, communication, and legal authority are offered. CONCLUSIONS This research has implications for the national EPH infrastructure. Recommendations offered are consistent with the CDCs findings in A National Strategy to Revitalize Environmental Public Health Services. These findings and recommendations offer opportunities to facilitate the advancement of an EPH system to better protect the nations health.

Integrating Health into Local Climate Response: Lessons from the U.S. CDC Climate-Ready States and Cities Initiative

Summary: Public health has potential to serve as a frame to convey the urgency of behavior change needed to adapt to a changing climate and reduce greenhouse gas emissions. Local governments form the backbone of climate-related public health preparedness. Yet local health agencies are often inadequately prepared and poorly integrated into climate change assessments and plans. We reviewed the climate health profiles of 16 states and two cities participating in the U.S. Centers for Disease Control and Prevention (CDC)’s Climate-Ready States and Cities Initiative (CRSCI) that aims to build local capacity to assess and respond to the health impacts of climate change. Following recommendations from a recent expert panel strategic review, we present illustrations of emerging promising practice and future directions. We found that CRSCI has strengthened climate preparedness and response in local public health agencies by identifying critical climate-health impacts and vulnerable populations, and has helped integrate health more fully into broader climate planning. Promising practice was found in all three recommendation areas identified by the expert panel (leveraging partnerships, refining assessment methodologies and enhancing communications), particularly with regard to health impacts of extreme heat. Vast needs remain, however, suggesting the need to disseminate CRSCI experience to non-grantees. In conclusion, the CRSCI program approach and selected activities illustrate a way forward toward robust, targeted local preparedness and response that may serve as a useful example for public health departments in the United States and internationally, particularly at a time of uncertain commitment to climate change agreements at the national level. https://doi.org/10.1289/EHP1838