Incident Response:Occupational and Environmental Health

Division of Environmental and Occupational Disease ControlCalifornia Department of Public Health

Celia Golden, MD, MPHcelia.golden@cdph.ca.gov

Slides created by Rupali Das, MD, MPH

Working Together for All Hazards ReadinessSan Joaquin County

August 20, 2008

Division of Environmental and Occupational Disease Control (DEODC)

Environmental Health Investigation Occupational Health Environmental Health Laboratory Childhood Lead Poisoning Prevention

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)

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

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

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

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

Population Injured in Chemical Incidents

Based on 4,425 victims reported to ATSDR’s HSEES, 1999-2000

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

Response Workers are Varied

Law enforcement

EMT, fire fighters

Health care providers

Public health agencies

Cleanup, remediation, construction

…and so are Hazards

Chemical Thermal Infectious Mechanical Ergonomic Mental stress

Chemicals Detected at WTC SiteSampled 9/13/01—1/11/02

% above OSHA StandardAcid gases 1.6Asbestos 12.6/0*Carbon monoxide 0.02Metals 5.1Noise 35.6Respirable silica 6.9Total dust 2.8Polynuclear aromatic 7.3 hydrocarbons

Photo: The New Yorker, May 20, 2002

http://www.osha.gov/nyc-disaster/summary.html*Final analysis used TEM

Other substances detected: benzene, dioxin, Freon, mercury

Injury Pattern Among Rescue Workers at WTC Site

% NYFD workers

24 hrs.N= 240

11 mos.N= 10,116

Respiratory† 25.7 18.5

Trauma 38.1

Eye 10.4

Systemic 31.3

Psychological 3.3 12.6

† 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.

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

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)

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

Metam Sodium Spill Sacramento River, July 1991

Liquid metam + water MITC in air, water

Cal/EPA data, 1991

Emergency Room VisitsDays 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%

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.

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

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

Public Health Response Tools

California Poison Control System Rapid Response Registry Survey Modules

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

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

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

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

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

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

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

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

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

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