6

Enhancing Operational Response

The response to disasters, including wildfires, can encompass a wide range of activities. The four presenters at the workshop who discussed operational response therefore framed their remarks in specific contexts: protecting people from wildfire smoke, detecting and treating mental health conditions, treating burns, and taking advantage of the expertise of public health departments.

ENHANCING OPERATIONAL RESPONSE TO PROTECT CARDIOPULMONARY HEALTH

John Balmes, professor of occupational and environmental medicine at the Zuckerberg San Francisco General Hospital and Trauma Center, discussed some of the many ways in which improved planning and readiness on the part of the public health infrastructure and health care providers can reduce morbidity and mortality due to wildfire smoke exposure. He began by citing the five pre-fire season recommendations for people with preexisting heart and lung disease contained in the document Wildfire Smoke: A Guide for Public Health Officials (EPA et al., 2016):

1. Have an adequate supply of medication.
2. Have a written asthma plan.
3. If you plan to use a portable air cleaner, buy an appropriately sized one before the smoke emergency.
4. Contact a health care provider if your condition worsens when you are exposed to smoke.
5. Only use appropriate respiratory protection.

Public health responses are initiated based on the U.S. Environmental Protection Agency’s (EPA’s) Air Quality Index (AQI), in which “good” is 0–50, “moderate” is 51–100, “unhealthy for sensitive groups” is 101–150, “unhealthy” is 151–200, “very unhealthy” is 201–300, and “hazardous” is more than 300. The AQI reflects fine particulate matter, PM_2.5, but not in a linear fashion, Balmes observed. Also, the risk bins are somewhat arbitrary. The AQI is based on both ozone and PM_2.5 levels, and the AQI, though often reported hourly, cannot be calculated without estimating 24-hour data for PM_2.5, which requires a model that adds complexity to the measure. Though Balmes did not suggest a replacement for the AQI, he said that he tends to think in terms of micrograms per meter cubed, “because I understand the health effects of that and what those levels mean.”

In a report reviewing the evidence involving advisory messages on wildfire smoke, the British Columbia Centre for Disease Control (2014) found limited evidence in the peer-reviewed literature about the effectiveness of public service advisories (PSAs). It also found that simple and nontechnical messages were best recalled and that some populations are less likely to hear PSAs. Compliance was best for “stay indoors” and “reduce outdoor physical activity,” and both recall and compliance depended on socio-demographic characteristics.

In related research, Sugerman et al. (2012) surveyed 1,802 respondents, 88 percent of whom reported hearing fire-related health messages and 98 percent of whom understood the messages they heard. Respondents

complied with most to all of the nontechnical health messages: staying inside the home (59 percent), avoiding outdoor exercise (88 percent), and keeping windows closed (76 percent). Less than 5 percent recalled hearing technical messages to place air conditioners on recirculate, use portable high-efficiency particulate air (HEPA) filtration devices (air cleaners), or use N95 masks during ash cleanup, and fewer than 10 percent of all respondents followed these specific recommendations.

Okugami et al. (2014) assessed Twitter data regarding asthma symptoms during a bushfire in New South Wales, Australia. They found that using this social network platform can be helpful for both syndromic surveillance and health management, and in some surveys, respondents reported liking personal communications better than PSAs. In another project, Rappold et al. (2014) simulated the effectiveness of public health forecast-based interventions in adults with asthma and congestive heart failure. Though this was a modeling study, they found that triggering interventions at lower PM_2.5 thresholds with good compliance yielded the greatest risk reduction.

Mott et al. (2002) studied an intervention among the Hoopa Valley Tribe in California following a large fire that burned for 2 months and produced poor air quality. The investigators documented increased health care utilization for lower respiratory illness, and recollection of PSAs was associated with reduced odds of reporting adverse respiratory health effects. In addition, Henderson et al. (2005) determined that HEPA cleaners work well for reducing PM_2.5 from prescribed burns and wildfires.

Mott et al. (2002) also looked at HEPA cleaners and found that greater use of these devices reduced reported respiratory symptoms by 46 percent. However, this group found that the use of N95 face masks did not cause a reduction in reported respiratory symptoms. In contrast, a study of the 2003 southern California wildfires reported that children who did not wear face masks reported twice the rate of respiratory symptoms (Künzli et al., 2006), and a study of a 1997 haze disaster in Indonesia had similar findings (Kunii et al., 2002). Balmes reported that virtually no evidence exists on the effects of clean-air shelters in mitigating acute respiratory health effects, and that evacuations have not demonstrated evidence of effectiveness, possibly because evacuees tend to return before a wildfire smoke event is over.

Balmes also discussed the responses of the University of California (UC), Berkeley, to the 2017 northern California wildfires. On Friday afternoon, October 13, during the Tubbs Fire, the AQI level was near 200 in the San Francisco Bay Area. UC Berkeley issued an email to all of the faculty and staff saying that they should stay inside, not exercise outdoors, and consider wearing an N95 mask if they had to go outside. However, the university did not cancel classes, and it did not cancel a televised football game with Washington State that evening, because the

AQI was below 200 and the National Collegiate Athletic Association only requires canceling a game if the level is above 200.

UC Berkeley learned a lesson from the resulting outcry. After the Camp Fire, the AQI levels in Berkeley went above 200 and were projected to stay high. UC Berkeley canceled classes but did not close its campus because some of the campus buildings are well filtered and had low PM_2.5 levels inside. But UC Berkeley did postpone a football game with Stanford University.

In Sacramento, the AQI was more than 300 during the Camp Fire, and in Yuba City it was more than 400. The City of Sacramento started providing free N95 masks at fire stations, but the Sacramento County Health Department advised against wearing N95 masks, saying that they contributed to a false sense of protection and could pose safety issues, especially for people with preexisting heart and lung disease. “That’s not correct information,” said Balmes. “The work of breathing does not increase substantially wearing an N95. It’s uncomfortable. Nobody likes to wear them. But they’re not much of a risk to most people.”

Balmes concluded by describing work by a cardiologist, Robert Brook, who has spent his career studying the cardiovascular effects of air pollution (Brook and Rajagopalan, 2017). Informally, Brook has calculated that the number of people who would need to wear masks to prevent one acute health care event is about 370,000. Even for people with preexisting heart disease, 12,000 would need to wear masks to prevent one health care utilization event, and for people without preexisting heart or lung disease, 1 million people would have to wear N95 masks properly to prevent one health care utilization. Balmes quoted Fisk and Chan (2017, p. 191), who similarly pointed out, “The fraction of the exposed population with a hospital admission attributable to wildfire smoke is small; thus, the costs of implementing filtration-based interventions in every household far exceed the economic benefits.”

EVIDENCE-BASED AND TRAUMA-INFORMED PSYCHOLOGICAL RESPONSE TO DISASTERS

Children and adults can progress along different pathways following acute traumatic events, noted Merritt Schreiber, professor of clinical pediatrics at the Harbor–UCLA Medical Center/David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Probably the two most common are a resilience pathway, in which they return to normal after a

period of disequilibrium, and a chronic dysfunction pathway, in which they do not return to normal. But the details of these pathways can be important, Schreiber noted. For example, people can develop symptoms associated with posttraumatic stress disorder (PTSD) symptoms, such as insomnia or fear of recurrence, but the symptoms are not necessarily syndromal, in that they do not form the cluster necessary to make a diagnosis and, most importantly, do not result in functional impairment in school, at home, or in the community. In other cases, people develop new disorders, such as PTSD or depression, that they have not had before; following disasters, this number may be as high as 30 to 40 percent, Schreiber said. First responders also have increased risk, with 10 to 20 percent on average developing a new incidence disorder. Furthermore, local responders get a “double whammy,” in that they are affected through their response role and in their own lives as community members. In addition, people can have preexisting mental illnesses, severe emotional disturbance, or health and social disparities, all of which interact with their experiences during disasters.

Schreiber’s work has focused on determining who is headed toward a new disorder very early on at the time of the event, and who will require more than psychological first aid or nonspecific strategies. If people in this high-risk subset can be reached within 30 days and given relatively brief evidence-based interventions, those disorders can be mitigated and possibly prevented. “There is an untapped preventative window,” he said. “I call that the golden month.”

As an example of this approach, he cited a study from Australia that looked at an adult population that had suffered acute injuries. People who received 4 hours of a manualized evidence-based treatment demonstrated reliable differences between matched controls even 4 years later. “Four hours gives you 4 years of significant clinical improvement,” he said. “That’s a pretty good investment.” Yet, this approach is rarely taken, not even with children, who are the single highest risk group and can be significantly impaired in school even with subsyndromal symptoms.

Schreiber also cited work done after Hurricane Katrina, where children were five times more likely to have a new severe emotional disturbance after the event (McLaughlin et al., 2009), which meant that they had severe symptoms with impairment in more than one setting, such as at home and at school. “It’s not just a diagnosis, it’s a significant one.” Similarly, adults who evacuated from the 2016 Fort McMurray wildfires in Canada had rates of PTSD, depression, and other diagnoses in the range of 30 percent (Ouelett and Morin, 2019).

Adverse childhood experiences can exacerbate these effects. After a wildfire in Laguna, children who experienced exposure and had persistent stressors like home loss or home displacement had a variety of difficulties.

It was more difficult for them to focus in school. They had differences in levels of both PTSD and depression.

Schreiber and his colleagues have been working on an evidence-based procedure to decide who needs what. “One size doesn’t fit all,” he said, “but we don’t figure out who’s at risk and who’s not. And we don’t link them to recovery and to services across the recovery trajectory.” As an example of such a tool, he cited a model developed after Hurricane Katrina that linked people with a definite disorder to intervention 7 to 12 months after the event. “We can do a lot better than 7 to 12 months,” he said. “We can get to people before they’re symptomatic. The interventions are shorter. They’re less expensive for whoever the payer is. And there’s a lot less secondary impairment.”

The model he developed, with funding from the Substance Abuse and Mental Health Services Administration, is called the National Children’s Disaster Mental Health Concept of Operations (Schreiber, 2011). It takes population-level risk metrics across such touch points as human services and disaster systems of care and does stepped triage to care. The high-risk subset is linked to secondary evaluation and to an evidence-based intervention if they need it and want it. “We try to interrupt that cycle much earlier than usual.” This triage information is then linked to scalable cost-effective interventions like telehealth. “Basically, our tool identifies risk levels, and then we link individuals at various levels of risk to the appropriate scaled intervention.”

The tool is not a typical symptom screen for PTSD, he said. It does not use symptoms, which he termed unreliable indicators of definitive risk in the acute period. “You over-identify people as having a disorder if you just use symptoms in the first 30–45 days, and you also miss perhaps some of the most complex PTSD cases.” Using a Web app, nonprofessionals can enter information about what is happening to people, not what they are feeling. “Symptoms are great indicators 30 to 45 days post the initial event, [but] they don’t reliably discern who’s at risk versus who’s having expectable distress and likely resilience.” The tool is easy to learn and takes less than a minute to triage an individual. “It is integrating mental health into the rest of the health emergency response,” said Schreiber. The tool matches up to the Federal Emergency Management Agency’s predictive analytics, so it generates the numbers of people at risk subdivided by children and first responders. Then a gap analysis can determine how to scale a response.

For the Napa wildfires, Schreiber said, Napa County was able to complete 2,700 triage encounters in about 4 days. Besides identifying a high-risk subset, the tool yielded the average acuity over time plus levels of comorbidity. It identified clusters, so that resources could be matched to what people were experiencing. A component looked for unaccompanied children, placing 0.4 percent of them into this category. In a subsequent

use of the tool following Superstorm Sandy, the tool used about 20,000 encounters to inform operational decisions and identify high-risk areas. “It’s all in the implementation,” he concluded.

In response to a question, Schreiber pointed out that the tool is designed to use “quiet questions.” Items to be observed do not require extensive interviewer training or reveal potentially stigmatizing information about internalized mental health conditions. Schreiber said that he is particularly interested in having the tool used in a major event to gauge its impact on that scale.

He also addressed a question about intervening too early so that a problem is exacerbated. The issue, he said, is tailoring responses for the individual. A one-size-fits-all approach based on distress can have negative effects. For example, asking someone to recall their worst moment can retraumatize them. But individualized approaches avoid those pitfalls. “When you target interventions to match needs, they’re generally quite well accepted.”

BURN-DISASTER RESPONSE

According to Dai et al. (2017), the frequency of burn disasters rose substantially between the periods 1990–2000 and 2001–2015. This number is going up for a variety of reasons, observed Tina Palmieri, assistant chief of burn surgery at Shriners Hospitals for Children–Northern California and director of the UC Davis Firefighters Burn Institute Regional Burn Center. Industrial incidents have been increasing. Wildfires have been occurring in many countries, some of which have so many that they do not even report the numbers. “If you’ve ever traveled in Africa, they just accept that there are wildfires and that people are going to be part of that equation.” Structure fires, terrorist attacks, and transportation accidents all result in burns.

Are people ready for the increasing number of burn disasters, asked Palmieri. “Yes and no” was her response. Burn center referral guidelines are “fantastic at triaging,” she said. Advanced Burn Life Support courses have provided many people with the basics of how to take care of someone who has been burned, which is “a huge step forward.” National disaster austere guidelines outline what people can do if they face a shortage of burn supplies. The United States is divided into five regions that each have regional disaster teams. Disaster triage tables provide guidelines for immediate care, triage algorithms, and acute transportation guidelines.

The result has been substantial progress in communications networks with funding for disaster preparedness, equipment, local infrastructure, and

education for providers, Palmieri said. Even as the number of disasters in the world has increased, the number of reported deaths has declined.

Nevertheless, problems persist. Burns are not a required training rotation in U.S. general surgical training, and the relatively small number of burn centers limits exposure. “Emergency room doctors learn from other emergency room doctors on this,” said Palmieri, “so the person you get treating your burn may or may not have had much experience in burn care.” Also, the overall decrease in burn incidence has resulted in a loss of wound care knowledge, and the rapid transport to burn centers has caused a loss of local skills and supplies. “There’s an imperative for hospitals to be lean. The downside of that is if there’s a disaster, you don’t have that backup.” The average error in estimating burn size by a non-burn provider is about 20 percent, both over and under, so a 50 percent burn could be anywhere from 30 to 70 percent. “Think about how you’re going to project your supply requirements with that kind of error. It’s very difficult.”

The number of burn centers has decreased. The United States currently has 123, Palmieri reported, representing fewer than 1,800 beds. If the 9/11 terrorist attacks had produced 1,000 burn victims, as they could have if one of the jets had made a slight turn, “it would have completely overwhelmed the system,” she said. Regionalization has meant longer transport times, and burns require a large number of resources. The average burn patient takes at least 40 medications per day. “Think of the logistics of trying to get 40 meds. A person with heart failure post-disaster can’t even get three. Forty in a disaster would be hard,” Palmieri stated.

Burn centers are unevenly distributed, with some states, like Idaho and Montana, having none, and not all are verified by the American Burn Association, Palmieri observed. With a limited number of beds, 85 percent of the approximately 1,800 are occupied at any one time. On a regional basis, the western region has 24 burn centers with a total of 390 beds. On average, 127 beds are available, with a surge capacity to 219. Even California, which has the most burn centers, has issues, Palmieri said. It is a large state, not all burn centers are verified, hospitals are overcrowded, and medical assets are unevenly distributed.

The Camp Fire provides a good example of the difficulties. It was the deadliest fire in California history, with at least 85 people killed. The area had a single hospital, and the nearest burn center was 90 miles away. Much of the triage happened at UC Davis, which fortunately has one of the top five burn centers in the United States. Patients arrived at UC Davis with no warning, and no one knew if or when new patients would be arriving. The Western Region Burn Disaster Consortium triage network was activated. At that point, four staffed beds were immediately available in all of northern California for burn patients. “Everyone else was going to have to rapidly develop burn disaster treatment plans,” said Palmieri. In all of California,

53 beds were available, and the Western Region Burn Disaster Consortium had 97 immediately available adult beds and 3 pediatric beds, with surge capacity able to increase that number to 214. “This is a problem in a situation where wildfires are likely to happen again.”

Ten patients were admitted from the Camp Fire to UC Davis, and all received psychological interventions. Their average hospital bills were in the hundreds of thousands of dollars and some reached $1 million. Outpatient visits started the day after the fire.

The UC Davis Veterinary Emergency Response Team was also under severe pressure, Palmieri said. The most serious cases were transferred to UC Davis, including eight goats, two pigs, four horses, a llama, chickens, ducks, geese, and cats. “I’m still helping with some of these animals,” said Palmieri, “and there’s a llama still on the vet campus that hasn’t quite healed yet.”

Palmieri drew several lessons from this experience. Knowledgeable support staff is the rate-limiting factor in treatment, she said, “because you can have all the supplies you want, but if you have someone who does not know how to put a dressing on, it does not do any good to stock a ton of dressings.” Disaster declarations need specific service lines to deal with burns. Communication can be fragmented, whether because of limited cell phone signals or people being overwhelmed.

Wildfires are more than one and done, she said. “I was triaging for three days because the wind changed direction and suddenly there is a new evacuation area, which means there’s new risk for further injuries.” Also, hospitals can burn down, which can cause a rapid patient flux without warning.

Other medical issues complicate wildfire disasters. First, people do not stop getting burned from other causes because a wildfire has happened. Also, wounds from wildfires can be more severe and require more intensive treatment than simple flame burns. People can be loyal to their houses and animals and they often lack knowledge of evacuation routes. Animals need to be included in disaster planning, she said, since people can be hard to separate from their nonhuman companions.

Palmieri called for better integration of specialty consortia at the local, state, and federal levels. “If we all have our own plans, it’s great for our own worlds, but our worlds need to interact.” More guidelines need to be developed, and more people need to get burn-specific training, she said. “More disasters will happen,” she concluded. “The clock is ticking, and we need to be prepared.”

LOS ANGELES COUNTY PUBLIC HEALTH EMERGENCY OPERATIONAL RESPONSE

The Los Angeles County operation area covers 4,000 square miles and encompasses 88 cities, including the city of Los Angeles. The county has more than 10 million residents speaking more than 200 languages, with 45 million visitors coming to the county each year. It has 100 hospitals, 47 law enforcement agencies, 27 fire agencies, and more than 80 school districts.

The Emergency Preparedness and Response Division is located within the Los Angeles County Department of Public Health and is responsible for emergency preparedness, response, and recovery, said the division’s director, Stella Fogleman. It works with partner agencies to assess and prioritize threats and hazards to public health in Los Angeles County, develops collaborative (whole community) emergency and disaster plans with partner response agencies and community partners, develops educational resources, and conducts community outreach efforts to build preparedness and resilience. It provides training to the Department of Public Health’s staff and partners, maintains 24/7 readiness to respond to emergencies and coordinate public health responses, attains and manages emergency preparedness grant funding, and conducts and coordinates public health emergency responses. In the most recent hazard vulnerability assessment, extreme heat and wildfires were at the top of the division’s priorities.

Public health staff bring a different set of skills to disaster responses than do first responders, said Fogleman. Decision making in public health is data driven, evidence based, community inclusive, and culturally inclusive. Public health considers environmental health, occupational health and safety, wellness, health promotion, and injury prevention—in addition to responding to an emergency. “There’s a lot that we bring to the table.”

Public health has a strong presence in communities. It works with people speaking different languages and having different cultures on a day-to-day basis. “With that understanding, we can help provide the rest of our fellow responders with additional layers to our response,” she said. In an emergency response, public health is on the scene, issues orders if necessary, and reports directly to the health officer. Public health emergency management provides organization and coordination for tactical responses and implements incident command management systems.

Fogleman used the Woolsey Fire to illustrate her division’s role. The Woolsey Fire started on November 8, 2018, and was officially declared out on November 21. It burned almost 100,000 acres, destroyed more than 1,500 homes, damaged about 350 other homes and structures, injured 3 firefighters, killed 3 residents, forced the evacuations of more than 295,000 people, and cut power to nearly 40,000. Moreover, the mass shooting at the

Borderline Bar and Grill in Thousand Oaks occurred the night before the fire started, and some of the survivors of the shooting had to evacuate their homes.

Media reports tended to focus on the residences in the hills, where well-resourced people lived. But people in more hidden populations were also strongly affected, Fogleman said, along with those in the “Malibu mansions.”

On the day the fire started, Department of Public Health first responders received notification of a growing wildfire in Ventura County and anticipated that the fire would spread into Los Angeles County. They deployed to a field command post and briefed a policy group consisting of public health officials, who stood up the emergency management structure. The department had a variety of responsibilities in the Woolsey Fire, including the following:

• Smoke
• Contaminated debris
• Patient sheltering
• Sheltering operations
• Food safety
• Disease control
• Sewage systems
• Public information
• Water systems

An especially important role is notifying the public about what is happening and what health protective measures they should be taking, Fogleman said. Common questions might include whether to wear masks, close down schools, or go outside. “As quickly, effectively, and concisely as possible, [we] get out our messaging on our website and social media, engaging closely with media to try to get our messages out before other people start jumping on.” The goal is for messages to be simple, hearable, accessible, and quickly available to people.

During the Woolsey Fire, the Department of Public Health had multiple objectives:

• Develop, disseminate, and coordinate accurate and timely information on ways the public can protect themselves from negative health outcomes, including ways to handle emotional distress and trauma.
• Coordinate with and support partner agencies to address the public health, medical, mental/behavioral health, and human service needs of those in shelters, including persons with medical, access, and functional needs.

• Support monitoring, investigating, and controlling potential or known threats to human health of environmental origin.
• Begin planning for recovery operations, including supporting the needs of residents, businesses, and health care facilities.
• Support monitoring, investigating, and controlling potential or known threats and impacts to human health through surveillance, delivery of medical countermeasures, and nonmedical interventions.
• Provide public health and medical technical assistance and support.
• Manage the declaration of a public health emergency.

“We still have a lot of work to do in improving our response and our coordination with fellow agencies,” Fogleman acknowledged. But public health has a central role in response and recovery, she observed.

In response to a question specifically about the coordination of communications, Fogleman observed that the Department of Public Health seeks to communicate as quickly as possible with the state, and it “pays close attention to what the state is putting out and looks at what we’re putting out.” The policy group, which includes both the leadership and subject-matter experts, puts special effort into thinking through the interventions it is recommending and making sure that they are as consistent as possible with the recommendations being disseminated by partner agencies. In some cases, public health guidance may be different than what others are saying. In those cases, “we try to give a heads up, and we try to manage that accordingly.” Responding quickly helps in this regard, despite the desire to try to make the message perfect.

In response to another question, Fogleman described the Empower database, which is used to track Medicare beneficiaries who have durable medical equipment in their home, and getting that information to first responders. The department works with its partner agencies to let them know about vulnerable people in an evacuation area. The system uses names and addresses rather than phone numbers, and it tracks a broad range of equipment. The Empower data have been used to inform evacuations for several different responses, including not only wildfires but power shutoffs, which utility companies are beginning to do preemptively when they see a risk for a fire hazard. However, the challenge of using this information is much greater in smaller counties, which have fewer resources. “We’re happy to support other counties,” Fogleman said. “If we can receive the data and clean it and get it back to them, or we can have some sort of regional workgroup or support, that would be helpful.”

DISCUSSION

The moderator of the session on response, Suzet McKinney, a member of the planning committee for this workshop and co-chair of the National Academies’ Forum on Medical and Public Health Preparedness for Disasters and Emergencies, pointed out that wildfires can expose large numbers of people in urban areas to high levels of smoke containing a number of hazardous gases, compounds, and other pollutants that can cause extreme adverse health effects. They can also have mental health effects on those exposed, including children. For example, a study by Brown et al. (2019) found evidence of significant increases in depression and suicidal thoughts among adolescents in two Canadian communities following these events. “As planners, responders, and stakeholders, we need to be planning and paying particular attention to how we will identify pediatric patients at highest risk for developing psychiatric symptoms after these disasters.”

Messaging and communication are among the many concerns during the operational response to any disaster, and particularly wildfires, she added. Public health messaging can help those who are affected understand evacuation orders, how to avoid injury, and overall protection strategies.

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