JOURNAL of Fifteen Dollars Environmentaldedicated to the Advancement of the Environmental Health Professional Healthvolume 81, No

JOURNAL OF fifteen dollars EnvironmentalDedicated to the advancement of the environmental health professional HealthVolume 81, No. 4 November 2018

Published by the National Environmental Health Association www.neha.org

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® SWEEPS is a database software system designed EnvironmentalDedicated to the advancement of the environmental health professional HealthVolume 81, No. 4 November 2018 to effectively manage ABOUT THE COVER ADVANCEMENT OF THE SCIENCE your resources, staff and Special Report: Beyond Zoonosis: The Mental Health Impacts of Rat Exposure Rats are a common on Impoverished Urban Neighborhoods ...... 8 problem in cities programs. worldwide. Most Community-Wide Recreational Water-Associated Outbreak of Cryptosporidiosis of the public and Control Strategies—Maricopa County, Arizona, 2016 ...... 14 health research has focused on disease transmission ADVANCEMENT OF THE PRACTICE related to rat exposure and infesta- Special Report: Navigating Degrees of Collaboration: A Proposed Framework tions; however, for Identifying and Implementing Health in All Policies ...... 22 little is known about the nonphysical consequences of rat Building Capacity: Building Capacity Through Project Agility ...... 30 exposure. This month’s cover article, “Beyond Zoonosis: The Mental Health Impacts of Rat Direct From ATSDR: Investigating Hazardous Substance Exposures Associated Exposure on Impoverished Urban Neighbor- With Mining or Smelting in United States Communities ...... 32 hoods,” explores the often-neglected impacts of rat exposure on mental health. Results of the Direct From CDC/EHS: Now What? A Tool to Help Commercial Fishermen article suggest that rat exposure consistently has Encountering Sea-Disposed Chemical Munitions ...... 34 a negative impact on mental health. By developing a better understanding of potential rat- related health risks—both mental and physi- ADVANCEMENT OF THE PRACTITIONER cal—public health ofﬁcials can better evaluate, reﬁne, and develop their policies regarding rats. Career Opportunities ...... 36 See page 8. Call SWEEPS Today to EH Calendar ...... 38 Cover photos © iStock Photo / Antagain “Make Your Data Work as Hard as You Do!” Resource Corner ...... 40 YOUR ASSOCIATION ADVERTISERS INDEX President’s Message: The Impacts of Climate Change Are at Our Doorstep ...... 6

Custom Data Processing...... 41 NEHA Organizational Members ...... 42

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5 GALLON FRESH WATER TANK FDA certifi ed. No cross Published monthly (except bimonthly in January/February and July/ Official Publication August) by the National Environmental Health Association, 720 S. contamination. Colorado Blvd., Suite 1000-N, Denver, CO 80246-1926. Phone: (303) 756- 9090; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 81, Number 4. Yearly subscription rates in U.S.: $150 6 GALLON WASTE WATER TANK (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and FDA certifi ed. 17% overfl ow don’t print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/JEH. CPM Sales Agreement Number 40045946. capacity. Claims must be fi led within 30 days domestic, 90 days foreign, Journal of Environmental Health © Copyright 2018, National Environmental Health Association FRONT SAFETY LOCKING CASTERS (ISSN 0022-0892) (no refunds). All rights reserved. Contents may be reproduced only missin the next Journal with permission of the managing editor. NSF certifi ed casters with of Environmental Health Opinions and conclusions expressed in articles, reviews, and other front safety brakes. contributions are those of the authors only and do not refl ect the policies Kristen Ruby-Cisneros, Managing Editor or views of NEHA. NEHA and the Journal of Environmental Health are not Ellen Kuwana, MS, Copy Editor liable or responsible for the accuracy of, or actions taken on the basis of, QUICK CONNECT any information stated herein.  Barriers to Managing Private Hughes design|communications, Design/Production NEHA and the Journal of Environmental Health reserve the right to reject NSF certifi ed Fresh Water Wells and Septic Systems in Cognition Studio, Cover Artwork any advertising copy. Advertisers and their agencies will assume liability for Tank connection. Soni Fink, Advertising the content of all advertisements printed and also assume responsibility for Underserved Communities For advertising call 303.756.9090, ext. 314 any claims arising therefrom against the publisher. Full text of this journal is available from ProQuest Information and ADA COMPLIANT WRIST HANDLES  Cooling Tower Maintenance Learning, (800) 521-0600, ext. 3781; (734) 973-7007; or www.proquest. com. The Journal of Environmental Health is indexed by Current Awareness Practices and Legionella Technical Editors in Biological Sciences, EBSCO, and Applied Science & Technology Index. It is abstracted by Wilson Applied Science & Technology Abstracts and TOP-FILL LIQUID SOAP DISPENSER Prevalence William A. Adler, MPH, RS EMBASE/Excerpta Medica. Retired (Minnesota Department of Health), Rochester, MN M-FOLD TOWEL DISPENSER All technical manuscripts submitted for publication are subject to peer  Estimation of the Prevalence of Gary Erbeck, MPH review. Contact the managing editor for Instructions for Authors, or visit www.neha.org/JEH. Undocumented and Abandoned Retired (County of San Diego Department of Environmental Health), San Diego, CA To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, [email protected]. Rural Private Wells Carolyn Hester Harvey, PhD, CIH, RS, DAAS, CHMM Periodicals postage paid at Denver, Colorado, and additional Eastern Kentucky University, Richmond, KY  E-Journal Article: Is Air Pollution a mailing offi ces. POSTMASTER: Send address changes to Journal of Thomas H. Hatfi eld, DrPH, REHS, DAAS Environmental Health, 720 S. Colorado Blvd., Suite 1000-N, Denver, Risk Factor for Sleep-Disordered California State University, Northridge, CA CO 80246-1926. Dhitinut Ratnapradipa, PhD, MCHES Breathing in Children? Printed on recycled paper. Sam Huston State University, Huntsville, TX Greater Nashville TN Area 1.866.663.1982· OzarkRiver.com 4 Volume 81 • Number 4

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 PRESIDENT’S MESSAGE

The Impacts of Climate Change Are at Our Doorstep

Vince Radke, MPH, RS, CP-FS, DLAAS, CPH

limate change refers to “any signifi - In September 2016, NEHA participated in a cant change in measures of climate We can no longer national online survey sponsored by ecoAmer- C (such as temperature or precipita- ica and Climate for Health to determine mem- tion) lasting for an extended period (decades stand on the doorstep. ber attitudes and behaviors on climate change. or longer)” (U.S. Environmental Protection NEHA invited its members to participate in Agency, 2016, p. 3). the online survey and 277 NEHA members In 1997, some 20 years ago, the National responded to the survey. The survey was also Environmental Health Agency (NEHA) and dangers of climate change. The report sent out nationally to others across the U.S. adopted a climate change position paper. In also discusses the prioritization and capacity It should be noted that NEHA members self- 2017, NEHA adopted an updated climate to assess and address the impacts of climate selected and the respondents might not refl ect change policy statement. In between those change. An additional resource is the Building a representative sample of the association’s years, additional research and evidence have Resilience Against Climate Effects (BRACE) membership. Due to space limitations, I will been documented that indicate climate change framework (Centers for Disease Control and present just a few results from the survey. The is continuing to have an impact on our lives. I Prevention, 2015). The framework’s fi ve-step entire survey report can be found at www. suggest we all read the NEHA policy statement process anticipates impacts, assesses associ- neha.org/sites/default/fi les/eh-topics/climate- on climate change (see references for the link). ated health vulnerabilities, and creates adap- change/ecoAmerica_Climate_Survey_NEHA_ Climate change is impacting all aspects of tive capacity to reduce exposures. US_Results_Sum_2016_09.pdf. our environmental health work—air, water, As environmental health professionals, • 83% of NEHA members believe climate vector control, food, safety, and the built envi- we cannot assess and address the impacts of change is happening (versus 83% nationally). ronment. The communities where we work and climate change by ourselves. This effort will • 78% of NEHA members agree we need to live are being impacted. We must address this take our entire communities, as well as other take action now to reduce pollution that impact now. We can address this impact with levels of government, nongovernmental orga- is causing climate change (versus 80% risk assessment, monitoring, planning, educa- nizations, policy makers, and the private sec- nationally). tion, and adaptation. If you have not started to tor. As environmental health professionals, • 90% of NEHA members believe clean address this impact of climate change in your part of our effort with other partners will water is a critical right to all (versus 90% community, you must start now. be to show both the health and economic nationally). There are several resources available to us. burden of climate change. Baseline data on • 89% of NEHA members have discussed cli- The Lancet Commission on Health and Cli- exposure and disease, if not available, will mate change with friends and family (ver- mate Change has proposed 10 policy recom- need to be obtained to quantify the impacts sus 69% nationally). mendations that can aid us, as environmental of climate change. Environmental health sur- In closing, I would like to quote the fi nal health professionals, to help our communities veillance activities will need to be undertaken paragraph of NEHA’s policy statement on cli- make changes to mitigate some of the impacts to monitor changes over time. Those popula- mate change (2017): of climate change (Watts et al., 2015). The tions already affected by socioeconomic ineq- Addressing climate change can be an National Association of County and City uities will be disproportionately burdened by overwhelming and daunting task, but Health Offi cials (2014) has produced a report the impacts of climate change. Efforts must when all individuals in a community that summarizes the results from local health be made to monitor and develop appropriate engage, prepare, and collaborate on department directors on the existence, causes, measures for these communities. effective climate change strategies, then

6 Volume 81 • Number 4

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partnerships and solutions arise. Evalu- References U.S. Environmental Protection Agency. ating baseline opinions, values, core Centers for Disease Control and Prevention. (2016). Climate change indicators in the beliefs, and identities of a community’s (2015). CDC’s Building Resilience Against Cli- United States, 2016, fourth edition (EPA diverse population will allow environ- mate Effects (BRACE) framework. Retrieved 430-R-16-004). Washington, DC: Author. mental health professionals to better from https://www.cdc.gov/climateandhealth/ Retrieved from https://www.epa.gov/sites/ understand how and where behavior BRACE.htm production/files/2016-08/documents/cli change can produce maximum results. National Association of County and City mate_indicators_2016.pdf Promoting long-term planning for cli- Health Officials. (2014). Are we ready? Watts, N., Adger, W.N., Agnolucci, P., Black- mate change is important. Communities Report 2: Preparing for the public health stock, J., Byass, P., Cai, W., . . . Costello, A. must create and be examples of more challenges of climate change. Washington, (2015). Health and climate change: Policy efﬁ cient and sustainable lifestyles, such DC: Author. responses to protect public health. Lancet, as using active and mass transportation, National Environmental Health Association. 386(10006), 1861–1914. reducing waste, and conserving energy (2017). Policy statement: Climate change. and water. (pp. 4–5) Denver, CO: Author. Retrieved from https:// We can no longer stand on the door- www.neha.org/node/58947 step. [email protected]

NEHA and ecoAmerica’s Climate for Health have developed a 5-minute Did You video showcasing NEHA member success stories that address climate change impacts. Watch the video at www.neha.org/node/60356 to hear Know? their inspiring stories about strategies for community-level adaptation and mitigation, as well as strong? coalitions and collaborations.

he NEHA Endowment Foundation was established to enable NEHA to do more for the environmental health pro- T fession than its annual budget might allow. Special projects and programs supported by the foundation will be SUPPORT carried out for the sole purpose of advancing the profession and its practitioners. THE NEHA Individuals who have contributed to the foundation are listed below by club category. These listings are based on what people have actually donated to the foundation—not what they have pledged. Names will be published under ENDOWMENT the appropriate category for one year; additional contributions will move individuals to a different category in the FOUNDATION following year(s). For each of the categories, there are a number of ways NEHA recognizes and thanks contribu- tors to the foundation. If you are interested in contributing to the Endowment Foundation, please call NEHA at 303.756.9090. You can also donate online at www.neha.org/about-neha/donate. Thank you.

DELEGATE CLUB ($25–$99) Lynne Madison, RS Bob Custard, REHS, CP-FS Name in the Journal for one year. Hancock, MI Lovettsville, VA Sandra Long, REHS, RS Larry Ramdin, REHS, CP-FS, HHS David Dyjack, DrPH, CIH Plano, TX Salem, MA Denver, CO Priscilla Oliver, PhD Ned Therien, MPH Jeffrey J. and Mary E. Burdge Olympia, WA Charitable Trust Atlanta, GA Shawnee, KS Matthew Reighter, MPH, REHS, CP-FS 21st CENTURY CLUB George A. Morris, RS Seattle, WA ($500–$999) Name submitted in drawing for a free one-year Dousman, WI Tom Vyles, REHS/RS, CP-FS Peter M. Schmitt Flower Mound, TX NEHA membership and name in the Journal for one year. Shakopee, MN HONORARY MEMBERS CLUB LCDR James Speckhart, MS AFFILIATES CLUB ($100–$499) Silver Spring, MD ($2,500–$4,999) Letter from the NEHA president and name in the Leon Vinci, DHA, RS Name submitted in drawing for a free AEC Journal for one year. Roanoke, VA registration and name in the Journal for one year. Tim Hatch, MPA, REHS Montgomery, AL SUSTAINING MEMBERS CLUB EXECUTIVE CLUB AND ABOVE ($1,000–$2,499) ($5,000–$100,000) Iowa Public Health Association Des Moines, IA Name submitted in drawing for a free two-year NEHA Special invitation to the AEC President’s Reception membership and name in the Journal for one year. and name in the Journal for one year. Roy Kroeger, REHS Cheyenne, WY James J. Balsamo, Jr., MS, MPH, MHA, RS, CP-FS Vince Radke, MPH, RS, CP-FS, DLAAS, CPH Metairie, LA Atlanta, GA Adam London, MPA, RS Grand Rapids, MI Gavin F. Burdge Lemoyne, PA

November 2018 • Journal of Environmental Health 7

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ADVANCEMENT OF THE SCIENCE

 SPECIAL REPORT

Raymond Lam, MSc, CPHI(C) Beyond Zoonosis: The School of Population and Public Health University of British Columbia Mental Health Impacts Kaylee A. Byers, MSc University of British Columbia of Rat Exposure on Chelsea G. Himsworth, MVetSc, DVM, Dipl ACVP Impoverished Urban School of Population and Public Health University of British Columbia Neighborhoods

neighborhoods are often ill-equipped to deal Abstract Rats are a common problem in cities worldwide. with rat infestations because of low education and income, as well as fear of landlord Impoverished urban neighborhoods are disproportionately affected reprisal (Bashir, 2002). because factors associated with poverty promote rat infestations and rat– Although the majority of concerns regard- human contact. In public health, most studies have focused on disease ing urban rat infestations are centered around transmission, but little is known about the nonphysical consequences of this the risk of disease transmission, the inci- environmental exposure. Mental health often is neglected but is receiving dence of rat-associated illness in developed cities is relatively low (Battersby, Hirschhorn, increasing attention in public health research and practice. The objective & Amman, 2008; Battersby, Parsons, & Web- of this study was to use a systematic review and narrative synthesis of the ster, 2002). In the absence of immediate and published literature to explore the effect of rat exposure on mental health obvious public health threats, governmental among residents in impoverished urban neighborhoods. Although the bodies can become apathetic and/or reactive to rats and rat-related issues (McBride, 2013; literature addressing this topic was sparse, the results of this review suggest Staley, 2014). The potential nonphysical con- that rat exposure consistently has a negative impact on mental health. sequences of living with rats, however, have These effects can be elicited directly (e.g., fear of rat bites) or indirectly been largely ignored. (e.g., feeling of disempowerment from inability to tackle rat problems). By This blindspot is problematic because cur- developing a better understanding of potential rat-related health risks, both rent cultures of complacency regarding rat infestations could inadvertently be contrib- mental and physical, public health offi cials can better evaluate, refi ne, and uting to a growing incidence and prevalence develop their policies regarding rats. of mental health issues among already vulnerable populations. A lack of recognition regarding the potential mental health impacts of living with rats can, in turn, create a burden Introduction food (Clinton, 1969). Aging infrastructure, on the healthcare system when the root cause Society has a negative perception of rats (Rat- poor sanitation, high population/hous- of the problem can potentially be addressed tus spp.). From a health perspective, they are ing density, and poverty have been consis- more effectively and effi ciently upstream. the source of a number of zoonoses (diseases tently associated with urban rat infestations Mental health has been a neglected prob- transmitted to people from animals) that have (Himsworth et al., 2013; Johnson, Brag- lem in the fi eld of environmental health caused considerable human morbidity and don, Olson, Merlino, & Bonaparte, 2016). (Gong, Palmer, Gallacher, Marsden, & Fone, mortality around the world (Himsworth, Par- Many of these conditions are characteristic 2016). To address this, the World Health sons, Jardine, & Patrick, 2013). From a socio- of impoverished urban neighborhoods in Organization has launched the Comprehen- logical perspective, rats have become symbolic developed countries (Bashir, 2002; Hims- sive Mental Health Action Plan 2013–2020, of fi lth and destitution (Edelman, 2002). worth et al., 2013) and are beyond the con- with prevention and research as two of its Rats thrive in urban centers where human trol of individual residents, with control main objectives (Saxena, Funk, & Chisholm, environments provide easy access to harbor- resting in the hands of municipalities or 2013). Given the ubiquity of rats in the urban age (places where pests seek shelter) and landlords. Residents of impoverished urban environment, and the fact that rat infestations

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disproportionately affect populations that are in residents of urban neighborhoods. We household pests (rats, mice, and cockroaches), already marginalized and disadvantaged, it excluded literature focusing on the mental only rats had a significant negative impact on is important to understand the full scope of health impact of other pest species (e.g., mice), mental health; moreover, residents with rat potential rat-related health risk in terms of studies that did not pertain to urban centers infestations had poorer mental health than both physical and mental effects. The goal of (e.g., rural settings), and papers written in those without rat infestations. In the study, rat this review is to synthesize the published lit- languages other than English. Additionally, R. exposure specifically triggered somatization erature regarding the potential mental health Lam screened titles and abstracts to determine (headaches, dizziness, and stomach aches), impacts of rat infestations on residents living relevancy and then reviewed full text articles among other measures such as depression and in impoverished urban neighborhoods. to determine if the inclusion criteria were met. hostility (Zahner et al., 1985). Some studies have suggested that resi- Methods Results dents in impoverished urban neighbor- To conduct this study, we reviewed articles Our search yielded 756 articles, of which hoods develop passive acceptance of rats as in the following databases: Medline, Embase, 8 fulfilled the inclusion criteria; of these, 6 part of their environment (Battersby et al., Web of Science, PubMed, PsycINFO, and evaluated rat infestations (as part of rodent 2002; Zahner et al., 1985). In 2016, however, Cinahl. We conducted word searches using a infestations) as one component of a spectrum researchers examined perceptions of rats and combination of keywords and Medical Subject of housing and neighborhood factors affect- the mental health effects of rat exposure on Headings (MeSH) pertaining to three main ing health, including mental health. One several impoverished Baltimore, Maryland, concepts: rats (rats, rodents, rat infestation, article examined the psychological conse- neighborhoods (German & Latkin, 2016). rodent infestation, rodentia, Rattus norvegicus, quences of having pest infestations (includ- Residents reported that in general, rat sight- Rattus rattus, black rat, Norway rat, brown ing rats) within the home. Another paper ings were bothersome and that the level of rat), psychological effects (mental health, examined the impact of urban rat exposures disturbance was also proportional to the mental disorder, anxiety, stress, psychological as a community stressor. degree of exposure. Specifically, those who stress), and impoverished urban populations reported daily rat sightings perceived infes- (urban, poor, poverty, poverty areas, socio- Rat Exposure Has a Negative Impact tations to be most problematic and reported economic factors, slums, social class). The on Mental Health greater depressive symptoms compared with Boolean operators OR and AND were used to In substandard housing, pest infestations those exposed to rats less frequently. These combine keywords/MeSH terms within and have been cited as one of many mental health associations did not vary among demographic between concepts, respectively. Reference stressors (Duvall & Booth, 1978). Even being characteristics such as ethnicity, age, and chaining and manual citation searching of ref- cognizant of an infestation in their dwelling education. In fact, resident attitudes towards erence lists were used to supplement results. without any direct contact can be a source of rats were even more negative in areas with Two reviewers, R. Lam and C. Himsworth, anxiety for residents (Battersby et al., 2008). high rates of infestations compared with less screened this step to ensure the search scope A 3-year longitudinal study in Waterbury, problematic areas (German & Latkin, 2016). was refined to the research question. Connecticut, evaluated the effects of residen- We further limited the search scope to lit- tial pest infestations on the mental health of Causes of Rat-Related Mental erature that discussed the impact of rat infes- minority women residing in multiunit dwell- Health Impacts tations (including as part of general rodent ings using six psychiatric assessment scales The negative mental health impacts of rat infestations) on mental/psychological health (Zahner, Kasl, White, & Will, 1985). Among infestations can be either directly or indi-

November 2018 • Journal of Environmental Health 9

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rectly related to rat exposure. Fear of disease residents have limited resources to address evoked will be important for efficiently exposure and/or physical trauma (Clinton, rat infestations themselves (Mirowsky & and effectively preventing and addressing 1969; German & Latkin, 2016) can induce Ross, 1986). This helplessness undermines the resulting distress. For example, dealing stress through concern for personal or family the residents’ control over their own lives, with fears regarding disease transmission health and safety. It is of note that numerous which has been recognized as a key param- would be quite different from dealing with cases of rat bites have been documented in eter for distress (Mirowsky & Ross, 1986; feelings of helplessness related to poverty. substandard housing (Battersby et al., 2008; Seeman, 1959). Panti-May and coauthors (2017) high- Clinton, 1969). lighted that active participation of commu- With regard to indirect impacts, the inac- Mental Health Impacts of Other Pests nity members is necessary for implementation of landlords to address maintenance Results from studies on the mental health tion of successful rodent-control initiatives. issues, such as rodent infestations, has been effects of other urban pests are mixed. Bed Understanding the concerns of residents shown to elevate tenant stress levels; conflicts bug infestations have been associated with will allow program administrators to bet- arising from the infestations can result in the posttraumatic stress disorder (Goddard & ter engage communities by addressing threat of eviction or verbal abuse directed deShazo, 2012) and even the development their worries. On the other hand, if resi- at the tenants (Bachelder, Stewart, Felix, & of paranoid schizophrenia due to the social dent concerns are neglected, people can Sealy, 2016; Bashir, 2002). isolation experienced when others distance become disenfranchised towards control Finally, it is important to note that rat themselves for fear of acquiring the infesta- efforts (Lambropoulos et al., 1999). For infestations are one of a constellation of envi- tion (Rieder et al., 2012). Zahner and coau- example, if distress arises from concern for ronmental stressors experienced in impov- thors (1985), however, did not find that cock- children’s safety, communication can focus erished urban neighborhoods. For example, roach infestations had a significant impact on measures that reduce the likelihood of German and Latkin (2016) found that resi- on mental health. It is likely that the mental children’s exposure to rats. dents who perceived rat infestations as prob- health effects of infestations vary among pest • How does rat exposure negatively impact lematic also lived on blocks that had other species based on factors such as the nature mental health? Specifically, what symp- indicators of neighborhood disorder, such of interaction between the pest and humans, toms, conditions, etc., does this exposure as vacant properties and unkempt trash— persistence of the infestation, and social per- contribute to and what are the long-term even after adjusting for socioeconomic fac- ceptions of the pest. consequences? The existing literature sug- tors such as education and number of chil- Even among pests that have negative men- gests that the nonphysical consequences dren. Moreover, initial qualitative studies tal health impacts, the nature and mecha- of rat exposure can be highly variable, they performed identified rats, specifically, nism of those impacts are likely to be differ- perhaps as a result of different causes of as a commonly cited issue within “stressful” ent because of the different characteristics distress. For example, the manifestations neighborhood environments in Baltimore. of the pests and associated infestations. For of fears around disease transmission dif- Therefore, rats indeed can be a significant example, compared with rats, bed bugs are fer from those stemming from feelings of and independent environmental risk factor inconspicuous, localized to an infestation helplessness. Thus, it will be important to in these neighborhoods. site, and are not traditionally affiliated with understand the full range of potential men- disease transmission (Goddard & deShazo, tal health effects in order to help healthcare Discussion 2009). In this context, rats have a more sig- professionals identify and care for people nificant impact on mental health given they suffering from these effects. Summary of Findings are conspicuous, destructive, and affiliated • Are different demographics affected dif- The results of this review suggest that expo- with disease transmission and filth. ferently? There is evidence that residents sure to rats and rat infestations can result in impoverished urban neighborhoods are in negative mental health consequences for Knowledge Gaps and Priorities likely disproportionately affected by rat- residents in impoverished urban neighbor- for Future Study related mental health issues. It remains hoods. This negative effect is associated with Currently there is only a very small body to be determined, however, whether both exposures at home (Zahner et al., 1985) of literature regarding the impact of rats on more affluent demographics are similarly and as part of the general neighborhood mental health; therefore, the nuances of this affected and whether relative affluence environment (German & Latkin, 2016). relationship remain unclear. We suggest that is a protective factor. Also, within dis- Although rat exposure can trigger stress the following are the most significant knowl- advantaged communities, perhaps there directly, stress can also be elicited and exac- edge gaps and therefore should be priorities are specific groups that are particularly at erbated by indirect variables such as land- for future study: risk. For example, people in poor health, lord inaction (Bachelder et al., 2016; Bashir, • Why does rat exposure negatively impact older residents, or parents of young chil- 2002), feelings of helplessness (Mirowsky mental health? The above background dren might be further sensitized to the & Ross, 1986; Seeman, 1959), and concur- information gives us some ideas regard- negative impacts of rat exposure. This rent neighborhood disorder (German & ing the potential direct and indirect causes deeper understanding will help to identify Latkin, 2016). Mental health impacts can be of rat-related distress, but a more detailed groups that should be a priority or focus compounded by the fact that impoverished understanding of why this distress is for interventions.

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• Is there a dose-response relationship when found together, the risk of lung can- professionals to develop a better understand- between rat exposure and mental health cer is greater than the sum of their indi- ing of the full scope of rat-related health risks impacts? If there is a link between the fre- vidual effects (Lantz, Mendez, & Philbert, and impacts. quency and/or intensity of rat exposure, 2013). This effect would highlight the need On a broader social context, this relation- then rat-control campaigns could be effec- to address rats specifically, even within a ship between rat infestations and overall tive at reducing mental health impacts. disordered neighborhood. health impacts can be used as a lever for Additionally, if repeated and/or chronic • Are there interventions that can make peo- public health action to improve vulnerable exposure is a risk factor, then this finding ple more resilient to rat exposure? Given neighborhoods. That is, this understanding might highlight the need for prompt action that rat infestations often are difficult to could in turn provide a different perspective and diligent monitoring for recurrence of fully eliminate or prevent, it will be impor- from which policy makers, urban planners, infestations. tant to determine whether residents have and government officials can develop more • Are rats an independent risk factor for poor the ability to adapt to and cope with rat effective and holistic public health strate- mental health? Given that rat infestations infestations, or whether chronic exposure gies—ones that encompass not only the often are associated with general neighbor- leads to progressive mental health deterio- physical but also the mental and social well- hood disorder, the potential for confound- ration. Identifying factors that make resi- being of urban residents (World Health Orga- ing must be considered. It could be that the dents more resilient to rat-related mental nization, 1948). negative mental health impacts are due to health impacts could help to improve over- associated environmental stressors, such as all public health alone or in combination Acknowledgements: The authors would like substandard housing or crime, rather than with interventions that reduce rat exposure. to thank Dr. Mieke Koehoorn for her valu- exposure to rats themselves. If that is the able input in the development of this article. case, then addressing overall neighborhood Conclusion The authors would also like to thank Ursula disorder might be more important than Currently, health concerns regarding rat Ellis for her technical assistance with the addressing the infestations themselves. exposure are almost entirely based on the methods section. • Do rat infestations interact with other perceived threat of infectious diseases. Given environmental factors to impact mental the nonphysical impacts of rat exposure, Corresponding Author: Raymond Lam, School health? Alternatively, rats and other envi- this approach might lead to the neglect of a of Population and Public Health, University of ronmental factors might have an interac- far greater rat-related public health impact. British Columbia, 2206 East Mall, Vancouver, tive effect similar to how smoking and Information on how and why rats evoke men- BC, V6T 1Z3, Canada. radon are carcinogens on their own, but tal stress could allow environmental health E-mail: [email protected].

References Bachelder, A.E., Stewart, M.K., Felix, H.C., & Sealy, N. (2016). Edelman, B. (2002). ‘Rats are people, too!’: Rat-human relations re- Health complaints associated with poor rental housing conditions rated. Anthropology Today, 18(3), 3–8. in Arkansas: The only state without a landlord’s implied warranty German, D., & Latkin, C.A. (2016). Exposure to urban rats as a of habitability. Frontiers in Public Health, 4, 263. community stressor among low-income urban residents. Journal Bashir, S.A. (2002). Home is where the harm is: Inadequate housing of Community Psychology, 44(2), 249–262. as a public health crisis. American Journal of Public Health, 92(5), Goddard, J., & deShazo, R. (2009). Bed bugs (Cimex lectularius) and 733–738. clinical consequences of their bites. JAMA, 301(13), 1358–1366. Battersby, S., Hirschhorn, R.B., & Amman, B.R. (2008). Commen- Goddard, J., & deShazo, R. (2012). Psychological effects of bed bug sal rodents. In X. Bonnefoy, H. Kampen, & K. Sweeney (Eds.), attacks (Cimex lectularius L.). The American Journal of Medicine, Public health signiﬁcance of urban pests (pp. 387–419). Copenha- 125(1), 101–103. gen, Denmark: World Health Organization, Regional Ofﬁce for Gong, Y., Palmer, S., Gallacher, J., Marsden, T., & Fone, D. (2016). Europe. A systematic review of the relationship between objective mea- Battersby, S.A., Parsons, R., & Webster, J.P. (2002). Urban rat infes- surements of the urban environment and psychological distress. tations and the risk to public health. Journal of Environmental Environment International, 96, 48–57. Health Research, 1, 57–65. Himsworth, C.G., Parsons, K.L., Jardine, C., & Patrick, D.M. Clinton, J.M. (1969). Rats in urban America. Public Health Reports, (2013). Rats, cities, people, and pathogens: A systematic review 84(1), 1–7. and narrative synthesis of literature regarding the ecology of rat- Duvall, D., & Booth, A. (1978). The housing environment and wom- associated zoonoses in urban centers. Vector-Borne and Zoonotic en’s health. Journal of Health and Social Behavior, 19(4), 410–417. Diseases, 13(6), 349–359. continued on page 12

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References continued from page 11 Johnson, S., Bragdon, C., Olson, C., Merlino, M., & Bonaparte, S. lems: An experience in urban and rural areas of Yucatan, Mexico. (2016). Characteristics of the built environment and the presence Urban Ecosystems, 20(5), 983–988. of the Norway rat in New York City: Results from a neighborhood Rieder, E., Hamalian, G., Maloy, K., Streicker, E., Sjulson, L., & Ying, rat surveillance program, 2008–2010. Journal of Environmental P. (2012). Psychiatric consequences of actual versus feared and Health, 78(10), 22–29. perceived bed bug infestations: A case series examining a current Lambropoulos, A.S., Fine, J.B., Perbeck, A., Torres, D., Glass, G.E., epidemic. Psychosomatics, 53(1), 85–91. McHugh, P. , & Dorsey, E.A. (1999). Rodent control in urban Saxena, S., Funk, M., & Chisholm, D. (2013). World Health Assem- areas: An interdisciplinary approach. Journal of Environmental bly adopts comprehensive Mental Health Action Plan for 2013– Health, 61(6), 12–17. 2020. Lancet, 381(9882), 1970–1971. Lantz, P.M., Mendez, D., & Philbert, M.A. (2013). Radon, smoking, Seeman, M. (1959). On the meaning of alienation. American Socio- and lung cancer: The need to refocus radon control policy. Ameri- logical Review, 24(6), 783–791. Retrieved from https://www.jstor. can Journal of Public Health, 103(3), 443–447. org/stable/2088565?seq=1#page_scan_tab_contents McBride. J. (2013, December 18). RAT APOCALYPSE! Toron- Staley, R. (2014, October 15). Vancouver rat infestation raises health to’s new home invaders are growing in shocking numbers. concerns. The Georgia Straight. Retrieved from http://www.straight. Toronto Life. Retrieved from https://torontolife.com/city/toronto- com/life/749426/vancouver-rat-infestation-raises-health-concerns rat-apocalypse/ World Health Organization. (1948). Constitution of WHO: Principles. Mirowsky, J., & Ross, C.E. (1986). Social patterns of distress. Annual Geneva, Switzerland: Author. Retrieved from http://www.who.int/ Review of Sociology, 12(1), 23–45. about/mission/en Panti-May, J.A., Sodá-Tamayo, L., Gamboa-Tec, N., Cetina-Franco, Zahner, G.E., Kasl, S.V., White, M., & Will, J.C. (1985). Psycho- R., Cigarroa-Toledo, N., Machaín-Williams, C., . . . Hernández- logical consequences of infestation of the dwelling unit. American Betancourt, S.F. (2017). Perceptions of rodent-associated prob- Journal of Public Health, 75(11), 1303–1307.

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Sally Ann Iverson, MPH, DVM Community-Wide Recreational Centers for Disease Control and Prevention Water-Associated Outbreak of Maricopa County Department of Public Health Cryptosporidiosis and Control Nicole Fowle, MPH, LPN Maricopa County Department Strategies—Maricopa County, of Public Health Gregory Epperson, RS Maricopa County Environmental Arizona, 2016 Services Department Jennifer Collins, MPH Maricopa County Department of Public Health Abstract We describe a 2016 community-wide recreational Scott Zusy, MS, RS water-associated cryptosporidiosis outbreak investigation and response in Maricopa County Environmental Maricopa County, Arizona. Persons with a laboratory-conﬁrmed illness were Services Department interviewed using a standardized questionnaire that assessed exposures Jigna Narang, MPH 2 weeks before symptom onset. A convenience sample of managers and James Matthews, MPH, CPH operators of chlorine-treated public aquatic facilities was surveyed Maricopa County Department of Public Health regarding permanent supplemental treatment systems for Cryptosporidium. Michele C. Hlavsa, MPH, RN Among 437 cases identiﬁed (median age 12, range <1–75 years), 260 persons Dawn Roellig, PhD were interviewed. Public-treated recreational water was the most frequently Centers for Disease Control reported exposure (177, 68%) of interviewed persons; almost 1 in 5 (43, and Prevention 17%) swam when diarrhea was ongoing. Tammy Sylvester, MPH, RN After the 2016 outbreak, managers of some facilities expressed intentions Ronald Klein, RN Maricopa County Department to install supplementary water treatment systems, and by May 2017, at least of Public Health one large facility installed an ultraviolet light system. Strategies to prevent Rebecca Sunenshine, MD additional illness included community messaging, education, and targeted Centers for Disease Control remediation of affected facilities on the basis of interviews. Challenges to and Prevention remediation during a cryptosporidiosis outbreak in a large jurisdiction with Maricopa County Department of Public Health primarily outdoor pools underscore the importance of promoting healthy swimming practices that help prevent contamination from occurring.

Introduction in immunocompetent persons (Heymann, ciated outbreaks of cryptosporidiosis in the Cryptosporidiosis, caused by the parasite 2015). Additional symptoms include abdom- U.S. (Fill et al., 2017; D. Roellig, personal Cryptosporidium, has emerged as the leading inal cramping, anorexia, nausea, vomiting, communication, September 2016). cause of treated aquatic facility-associated and fever. Oocyst shedding in stool typically Cryptosporidium presents a unique chal- outbreaks in the U.S. (Hlavsa et al., 2015) ceases ≤2 weeks after complete symptom res- lenge to treated aquatic venues, such as pools, and was responsible for at least 32 outbreaks olution (Jokipii & Jokipii, 1986). waterparks, and interactive water features in 2016 (Hlavsa et al., 2017). Persons are The two species responsible for >90% of (splash pads) because infected persons shed infected when they ingest Cryptosporidium human cryptosporidiosis occurrences are C. the parasite in stool for an extended period oocysts, the parasite’s infectious life stage, in hominis, which is primarily maintained in a of time (Jokipii & Jokipii, 1986). Cryptospo- food or water contaminated with fecal mat- human-to-human transmission cycle, and C. ridium has a very low infectious dose, with ter, or after contact with infected persons or parvum (Bouzid, Hunter, Chalmers, & Tyler, ingestion of ≤10 oocysts being sufﬁcient to animals. Within 2 weeks (mean of 7 days), 2013). Among outbreak specimens subtyped cause illness (Chappell et al., 2006). Cryp- infected persons might experience profuse, since the 1990s, C. hominis IfA12G1 has been tosporidium is extremely chlorine tolerant watery diarrhea, which can last ≤30 days a leading etiology of recreational water-asso- and can survive in a properly chlorinated

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ingestion of nonpotable water. We also asked patients where they swam when experienc- TABLE 1 ing diarrhea and whether their occupation Demographics of Persons With Confirmed and Probable Outbreak- posed a risk for further parasite transmission Associated Cryptosporidiosis—Maricopa County, Arizona, 2016 (e.g., food handlers). Persons who reported HIV/AIDS, chemotherapy, leukemia or lym- Demographic Factor Confirmed Probable Overall phoma, organ or bone marrow transplant, or (n = 310) (n = 127) (N = 437) daily corticosteroid treatment of ≥20 mg were # (%) # (%) # (%) classified as immunocompromised. Sex All interviewed persons were advised to Male 148 (48) 60 (47) 208 (48) avoid swimming until 2 weeks after the complete resolution of diarrhea. On September 1, Female 160 (52) 64 (50) 224 (51) 2016, an alert was sent to schools and child Age (years) care centers. The alert included the follow- <5 74 (24) 28 (22) 102 (23) ing prevention and control recommenda- 5–14 99 (32) 37 (29) 136 (31) tions: educate staff and parents regarding 15–24 30 (10) 8 (6) 38 (9) the outbreak, exclude any child with diar- 25–44 71 (23) 43 (34) 114 (26) rhea, terminate all water play and swimming activities, practice good hand hygiene and 45–64 31 (10) 2 (2) 33 (8) diapering techniques, and clean and disinfect ≥65 5 (2) 1 (1) 6 (1) surfaces and objects to effectively remove and Note. Percentages of demographic subcategories might not total 100% due to rounding or missing data. inactivate Cryptosporidium oocysts. Remediation of public chlorine-treated aquatic venues such as pools, hot tubs and spas, water parks, and interactive water play pool for ≥7 days (Murphy, Arrowood, Hlavas, Methods facilities was targeted based on interview Beach, & Hill 2015; Shields, Hill, Arrowood, An outbreak case of cryptosporidiosis was responses. During August 5–18, remediation & Beach, 2008). A single fecal contamination defined as onset of diarrhea, abdominal of each public-treated aquatic venue was rec- event in a chlorine-treated aquatic venue can cramping, or vomiting in a resident of Mari- ommended when two or more persons from lead to infection in many swimmers and focal copa County during July 1–December 7, different households with confirmed cryp- outbreaks (i.e., involving one venue) can 2016. Laboratory-confirmed cases had evi- tosporidiosis cases reported exposure to the quickly turn into community-wide outbreaks dence of Cryptosporidium infection by one or same aquatic venue in the 2 weeks before if infected persons swim in multiple venues more of the following stool specimen tests: symptom onset or while diarrhea was ongo- or transmit the parasites in other settings direct fluorescent antibody test, polymerase ing. During August 19–December 7, 2016, such as child care facilities (Painter, Hlavsa, chain reaction (PCR) enzyme immunoas- remediation was recommended for every Collier, Xiao, & Yoder, 2015). say, light microscopy of stained specimen, public-treated aquatic venue that a person Maricopa County, Arizona, is home to and immunochromatographic (rapid card) with a confirmed case reported as a source >4 million persons who enjoy an extended tests. A probable case was defined as lack- of exposure in the 2 weeks before symptom swimming season at approximately 9,000 ing laboratory confirmation but having a onset or while diarrhea was ongoing. public-treated aquatic venues, of which >90% clinical illness and an epidemiologic link to Venues were referred to Maricopa County are outdoor venues. In early August 2016, a confirmed case. We based case detection on Environmental Services Department (MCESD) the Maricopa County Department of Public provider and electronic laboratory reports of and an employee from MCESD attempted to Health was notified of a cluster of diarrheal confirmed cryptosporidiosis cases; we identi- visit the venue within 24 hr of receiving the illness (later identified as C. hominis infec- fied probable cases through interviews with referral. Venue operators were counseled and tion) in members of a children’s baseball persons having a confirmed case. The Cen- given guidelines from CDC for hyperchlori- team that swam at a large treated aquatic ters for Disease Control and Prevention’s nation to inactivate Cryptosporidium (CDC, facility in Maricopa County (water park A) (CDC) CryptoNet laboratory performed the 2014). Remediation of residential pools was on July 22. Simultaneously, an increase in genotyping (Hlavsa et al., 2017). not recommended; residential pool owners laboratory-confirmed cases of cryptosporidi- We used a standardized questionnaire who expressed concern that a person with osis was detected through passive surveil- with patients or guardians of patients <18 cryptosporidiosis swam in their pool were lance. This article describes the investigation years who had been classified as a confirmed advised to close the pool for 2 weeks. and response for this cryptosporidiosis out- case; we assessed exposures in the 2 weeks On October 25, 2016, a self-administered break, including strategies to control the out- before symptom onset, including recreational survey was distributed to attendees of a com- break and remediate multiple public-treated water exposure, animal contact, ingestion of munity stakeholder meeting for facility oper- aquatic venues in the county. unpasteurized juice or dairy products, and ators to assess the response to the outbreak

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among public-treated aquatic facilities. This survey assessed the presence of supplemen- TABLE 2 tary water treatment systems, such as ultraviolet (UV) or ozone for Cryptosporidium in Exposures of Persons With Confirmed Outbreak-Associated 2016, and any plans for installation of sup- Cryptosporidiosis Before and After Illness Onset—Maricopa County, plementary systems before the 2017 swim- Arizona, 2016 (N = 260) ming season. Exposure Two Weeks Before While Experiencing Results Symptom Onset Diarrhea The outbreak was detected when a cluster of # (%) # (%) diarrheal illness among 35 (69%) of 51 visi- Any recreational water 205 (79) 43 (17) tors (children’s baseball team and their fam- Public-treated recreational water* 177 (68) 28 (11) ily members) to water park A was reported; Apartment or community pool 25 (10) 7 (3) symptom onset occurred 6–7 days after City or municipal pool 19 (7) 2 (1) visiting the water park. Additionally, interviews of 9 persons, not part of the baseball Gym or fitness center pool 24 (9) 7 (3) team cohort but who had positive laboratory Hotel or resort pool 24 (9) 6 (2) results for Cryptosporidium, revealed 5 per- School pool 9 (3) 0 (0) sons (56%) were exposed to both water park Splash pad 24 (9) 4 (2) A (a large facility reporting weekly atten- Water park 89 (34) 4 (2) dance of >10,000 visitors) and to multiple Natural water source 18 (7) 3 (1) other treated aquatic venues in the 2 weeks before symptom onset. C. hominis subtype Residential pool 61 (23) 20 (8) IfA12G1 was identified in four stool speci- Any animal contact 18 (7) – mens from persons in the baseball team clus- Consumption of unpasteurized juice, dairy, or 11 (4) – ter. One additional specimen identified as C. nonpotable water hominis, collected from a Maricopa County Worked at or attended a child care center 32 (12) 13 (5) resident later in the outbreak investigation, Worked as a food handler 5 (2) 2 (1) could not be subtyped. Worked in a healthcare setting 6 (2) 1 (<1) During July 1–December 7, 2016, a total Worked at a recreational aquatic venue 4 (2) 2 (1) of 437 cryptosporidiosis cases were identified as part of this outbreak: 310 (71%) were con- *Of the participants, 31 (12%) were exposed to multiple types of public, treated, and recreational aquatic venues before firmed and 127 (29%) were probable (Table symptom onset and 4 (2%) were exposed to multiple types of public, treated, and recreational aquatic venues while experiencing diarrhea. 1). The median age of persons classified with a confirmed or probable illness was 12 years (range <1–75) and 102/429 (23%) with recorded age were <5 years of age. The num- were hospitalized and 30 (12%) were clas- recreational aquatic venue, 2 (50%) worked ber of ill persons was equally male (208, 48%) sified as immunocompromised; of the 51 while experiencing diarrhea. and female (224, 51%), with the remainder hospitalized patients, 14 (27%) were also The most frequently reported exposure in (5, 1%) unknown. Sex distribution varied by immunocompromised. Of 114 (44%) persons the 2 weeks before symptom onset was swim- age: 140 (59%) of 238 persons <15 years were whose symptoms had resolved by the time of ming in any recreational water, including natu- male, compared with 68 (36%) of 191 per- interview, the mean duration of symptoms ral water venues, public-treated aquatic venues, sons ≥15 years who were male (χ2 p < .001). was 12.8 days (median 12 days). and residential or backyard pools (205, 79%). Of 310 persons with confirmed illness, Of 260 persons interviewed, 44 (17%) Exposure to public-treated aquatic venues was 260 (84%) were interviewed and 258 (99%) reported employment or attendance at one or reported most frequently (177, 86%), with 41% reported diarrhea, which was most frequently more facility type considered to be high risk (73) of those reporting exposure to water park characterized as watery (223, 86%). The for transmission; employment types included A. In contrast, out of the 260 people surveyed, two persons without diarrhea were children food handlers (2%), child care employees and exposure to natural water venues (18, 7%) and of 8 and 9 years who had other symptoms attendees (12%), healthcare workers (2%), private pools (61, 23%) was less frequent. (abdominal cramping or nausea) sufficient to and aquatics staff (2%) (Table 2). Thirteen Persons reported exposure to a variety of meet the case definition. Abdominal cramp- (41%) of the 32 persons with cryptosporidi- types of public-treated aquatic venues: 41 ing (221, 85%), nausea (190, 73%), anorexia osis who worked in or attended child care (16%) reported exposure to >1 (range 1–3) (158, 61%), fever (138, 53%), and vomiting worked or attended while ill (1 worked in public-treated aquatic venue in the 2 weeks (157, 60%) were also frequently reported. and 12 were <5 years of age who attended before symptom onset and 31 (12%) reported Additionally, 51 (20%) interviewed persons child care). Of 4 persons who worked at a exposure to >1 type of public-treated aquatic

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FIGURE 1 Conﬁrmed and Probable Cases of Cryptosporidiosis by Date of Illness Onset—Maricopa County, Arizona, 2016*

Initial Interventions Intensified Interventions 18

16 Schools Return to Session

14 Notification to Schools and Child Care Centers

8 # of Cases 6

0 1 6 11 16 21 26 31 5 10 15 20 25 30 4 9 14 19 24 29 4 9 14 19 24 29 3 8 13 18 23 28 3 July August September October November

Date of Illness Onset Confirmed Probable

*392 cases with date of illness onset available.

venue in the 2 weeks before symptom onset. tinued weekly hyperchlorination through On October 25, approximately 35 stake- Moreover, 43 (17%) persons with illness October 2016. The end of the community- holders, including public-treated aquatic admitted to swimming in recreational water wide outbreak of cryptosporidiosis was venue owners, managers, technicians, and while diarrhea was ongoing; of these persons, declared on December 7, 2016, two maximum employees, attended an informational meet- 28 (65%) swam in public-treated aquatic ven- incubation periods (28 days) after symptom ing for recreational water facility operators ues. Of the 55 persons who did not report onset for the last person with a confirmed case hosted by MCESD; 25 (71%) attendees com- swimming in recreational water in the 2 weeks who reported recreational water exposure. pleted some or all of a 12-question survey. before symptom onset, 26 (47%) reported con- MCESD recommendations for remedia- The majority of respondents represented tact with another ill person, 3 (1%) reported tion of treated aquatic venues throughout the smaller community or apartment pools. Of animal contact, and 2 (<1%) reported ingestion community targeted those identified during 19 respondents, 6 (32%) indicated that they of unpasteurized food or nonpotable water. interviews; two different strategies were used already had a UV light or ozone treatment Recreational water exposures occurred during August 5–18 and August 19–Decem- system for Cryptosporidium permanently in during June 28–November 9, 2016. In total, ber 7, as described in the methods section. place during the 2016 swimming season. 75 aquatic venues in Maricopa County were During the week of August 5, the majority of Four of nine who reported not having such reported as exposures by persons with con- public and private schools in the county for a system, including water park A, indicated firmed illness and all were visited by MCESD children <19 years reopened from summer that they were somewhat or very likely to within 24–48 hr of notification. Any public break (Figure 1). Remediation of residential acquire a permanent inline supplementary chlorinated aquatic venue that did not already pools was not recommended because they are treatment system and put it in place before have a permanent supplementary UV or ozone at lower risk of contamination and their own- the 2017 swimming season. When we fol- treatment system for Cryptosporidium in place ers are more likely to sustain chemical inju- lowed up with water park A management was remediated per CDC guidelines. Water ries while performing remediation by hyper- later in 2017, UV treatment systems had been park A was remediated on August 5 and con- chlorination (CDC, 2016). installed throughout the entire facility.

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TABLE 3 Summary of Remediation Strategies Used in Response to Select Recreational Water-Associated Outbreaks of Cryptosporidiosis

Authors Year Location Outbreak Scope Remediation Strategy Joce et al., 1991 1988 Doncaster, United Single recreational aquatic facility Pools at the implicated facility closed and drained Kingdom (UK) or remediated Puech et al., 2001 1998 New South Community-wide Swimming pool operators advised to superchlorinate Wales, Australia every 2 weeks; pools where Cryptosporidium oocysts were detected (n = 8) were closed and superchlorinated Lim, Varkey, Giesen, & 1998 Minnesota, U.S. Single swimming pool Implicated pool was closed and superchlorinated Edmonson, 2004 Mathieu et al., 2004 2000 Ohio, U.S. Single swimming pool Implicated pool was hyperchlorinated Centers for Disease Control 2000 Nebraska, U.S. Case patients swam at two main pools Pools A and B were closed for 2 weeks and Prevention (CDC), 2001 (A and B) and other local pools Causer et al., 2006 2001 Illinois, U.S. Single water park Implicated water park was hyperchlorinated Wheeler et al., 2007 2004 California, U.S. Single water park Water park was voluntarily closed for the season; required to perform weekly superchlorination upon reopening the following season CDC, 2007 2006 Colorado, U.S. Single water park Implicated water park pool and three other pools where one ill person swam were hyperchlorinated CDC, 2007 2006 Illinois, U.S. Swimming pool and water park Swimming pool was closed and water park was hyperchlorinated CDC, 2007 2006 South Carolina, Community-wide; multiple water parks Control measures (e.g., hyperchlorination) implemented U.S. and swimming pools at eight recreational water venues that were common exposures CDC, 2007 2006 Wyoming, U.S. Public pools and reservoir Largest public swimming pool in a two-county region was hyperchlorinated CDC, 2009 2007 Idaho, U.S. Single splash park Implicated splash park was closed and an ultraviolet light (UV) system was installed Coetzee, Edeghere, Orendi, 2007 Staffordshire, UK 13 swimming pools with one (water park Implicated pools were inspected; “urgent remedial Chalmers, & Morgan, 2008 A) considered a signiﬁcant contributor measures” were initiated for water park A to transmission CDC, 2008 2007 Utah, U.S. Community-wide; 450 recreational Initial: Venues in which patients reported swimming water venues reported during their incubation period or while ill were hyperchlorinated Intensiﬁed: All public-treated recreational water venues were required to remediate weekly McCann et al., 2014 2010 Manchester, UK Single swimming pool None; suspected contamination event was >2 weeks prior to inspection Ng-Hublin, Hargrave, 2012 Broome, Western Single swimming pool; one additional Swimming pool was remediated by superchlorination; Combs, & Ryan, 2015 Australia water playground and another UV light system was installed at water playground swimming pool possibly involved Fill et al., 2017 2015 Tennessee, U.S. Single swimming pool Implicated pool was closed and remediated

Discussion many recreational water-associated outbreaks or an epidemiologic link to someone with lab- This community-wide outbreak of crypto- in the U.S. Although the proportion of reported oratory evidence, likely leading to an overrep- sporidiosis was the largest detected outbreak hospitalizations (20%) in our investigation resentation of severe cases that required test- in Maricopa County’s history. Laboratory evi- was somewhat higher than those reported ing and medical care. dence and epidemiologic findings support that elsewhere (range 4%–8%) (CDC, 2008; Cope Demographics of the affected population this outbreak was primarily a recreational- et al., 2015), this difference might be a reflec- are consistent with other large-scale out- water associated outbreak caused by a subtype tion of our investigation’s more stringent case breaks of cryptosporidiosis in recreational of Cryptosporidium hominis responsible for definition, which required laboratory evidence water-associated outbreak surveillance and

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national case surveillance data (CDC, 2008; This outbreak was first identified by link- or increased chemical injuries were reported. Coetzee, Edeghere, Orendi, Chalmers, & ing a cluster of cases (in a children’s baseball Interventions did require increased pub- Morgan, 2008; Cope et al., 2015; Painter et team) and at least five other persons with lic health and environmental services staff al., 2015). laboratory-confirmed cryptosporidiosis to resources, however, and were implemented Younger children were disproportionately one large treated aquatic facility (water park for the duration of the outbreak. affected and sex distribution was approxi- A). In instances where a single aquatic venue Within the scope of a remediation strategy, mately equal overall, but varied by age when is suspected as an exposure, early remedia- the size and characteristics of a venue might a cutoff of 15 years was applied. Young chil- tion of that one venue can be effective in con- influence how hyperchlorination is accom- dren, especially diaper-age children, are dis- trolling an outbreak (CDC, 2007; Cope et al., plished. Trichloro-s-triazinetrione, a chlorine proportionately affected during recreational 2015; Fill et al., 2017). Staff at water park product that includes the chlorine stabilizer water-associated outbreaks, as they are more A hyperchlorinated within 24 hr of initial cyanuric acid, is commonly used in pools of likely to be infected with enteric pathogens, notification and voluntarily continued hyper- many smaller apartments, housing subdivi- contaminate recreational water due to no or chlorination on a weekly basis. Initial inter- sions, and motel pools in Maricopa County. limited toileting and hygiene skills, and swal- views, however, indicated that multiple addi- Cyanuric acid not only prevents the degrada- low recreational pool water (Dufour, Evans, tional aquatic venues were likely involved in tion of chlorine caused by UV sunlight but Behymer, & Cantú, 2006). Furthermore, they the outbreak, based on reports of exposure to also reduces the effectiveness of chlorine in swim in or are exposed to water frequented multiple aquatic venues, and some ill persons the inactivation of Cryptosporidium oocysts by other children; thus, this group is at higher reported exposure only to aquatic venues (Murphy et al., 2015). On July 22, 2017, risk of exposure to contaminated water. other than water park A. Therefore, the out- CDC released modified guidelines for reme- Swimming behaviors that likely contrib- break had likely already spread throughout diation of swimming pools using cyanuric uted to the propagation of this outbreak from the community before detection. acid (CDC, 2016). To remediate venues with a single venue to multiple venues across the Once an outbreak is no longer contained cyanuric acid in the water, these guidelines county included swimming at multiple ven- within a limited number of facilities (i.e., is recommend draining pools before hyperchlo- ues and multiple venue types (16% swam at throughout the community), management rination. In this outbreak, hyperchlorina- >1 public-treated aquatic venue; 12% swam at and remediation strategies become more tion proceeded as per previous guidelines, >1 type of public-treated aquatic venue) and complicated. Approaches recorded in pre- which might have reduced the effectiveness swimming with diarrhea (reported by 17% of vious community-wide outbreaks include of hyperchlorination. Pool operators and persons interviewed). These behaviors allow remediation on the basis of inspection find- sanitarians should be aware of these updated a limited number of ill persons to contami- ings, hyperchlorinating any treated recre- guidelines and how they can affect a commu- nate multiple venues within a community. ational aquatic venue used by ≥1 persons nity-wide remediation strategy. The investigation of at least one other large not all from the same household, and hyper- In addition to remediation, prevention community-wide recreational water-associ- chlorinating every public-treated aquatic messaging—including the recommendation ated cryptosporidiosis outbreak found that venue in the county on a biweekly to weekly to discontinue recreational activities involv- up to 33% of ill persons were exposed to >1 basis (Table 3). Initial interventions (tar- ing water—was provided to child care cen- aquatic venue in the 2 weeks before symptom geted hyperchlorination) were based on a ters. The strategy appeared effective in reduc- onset and that 20% of ill persons swam while balance of the potential costs of more ill- ing transmission in these high-risk settings; ill with diarrhea, also suggesting that these ness with the potential costs of pursuing a despite 32 persons working at or attending behaviors propagate larger-scale community- more aggressive strategy (e.g., hyperchlori- child care, no subsequent outbreaks of cryp- wide outbreaks (CDC, 2008). nation of every venue), which could have tosporidiosis in schools or child care centers Additionally, one half of ill aquatic staff resulted in shortages of pool chemicals and were detected. Substantial media attention with confirmed cryptosporidiosis reported thus delayed reopening of venues to patrons and promotion of healthy swimming web- that they continued to work while diarrhea (CDC, 2008). sites might have prevented some people from was ongoing, which also might have con- A moderate decline in cryptosporidiosis swimming when they had diarrhea (CDC, tributed to recontamination of large-scale incidence occurred in Maricopa County 2 2012), but the effectiveness of this interven- venues. Other swimming pool-related out- weeks after initial interventions, which tion cannot be assessed. breaks of cryptosporidiosis also have found coincided with the reopening of schools Permanent water treatment systems, such that swimmers and staff will continue to during the week of August 5, 2016; Crypto- as UV and ozone, have been recommended to swim with diarrhea (CDC, 2001; Cope et al., sporidium transmission, however, persisted help control cryptosporidiosis (CDC, 2007) 2015). Our outbreak investigation findings for an additional 2 weeks as evidenced by in chlorine-treated recreational aquatic ven- provide further support for aquatic facility reports of additional cases. On August 19, ues. These systems can help prevent the policies that encourage employees who are ill interventions were intensified so that any need for costly and prolonged closures and with diarrhea and whose duties require them treated aquatic venue reported was referred repeated remediation. At the community to be in the water to be reassigned duties that to MCESD for remediation. This strategy was stakeholder meeting, approximately 33% of keep them out of the water when experienc- generally acceptable to public venues in the respondents indicated that they had an inline ing diarrhea (Cope et al., 2015). county; no problems with chemical shortages supplementary treatment system for Cryp-

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tosporidium in place during the 2016 swim- Intensifying interventions by referring any outbreaks in child care centers. Hyperchlo- ming season, but this percentage is not likely pool for remediation that was reported by a rinating to control a community-wide cryp- representative of public recreational aquatic person with laboratory-confirmed cryptospo- tosporidiosis outbreak can be challenging, venues in Maricopa County, as only 8% of ridiosis, however, likely contributed to the especially in regions where the majority of affected venues are estimated to have had cessation of the outbreak. Our strategy struck pools are outdoors and use cyanuric acid. one of these systems in place at the time of a balance of ensuring that pools that had the Ultimately, a remediation strategy devel- the outbreak. At least one large treated facil- highest chance of being contaminated were oped by using interview responses and treat- ity affected by the outbreak (water park A) remediated without requiring hyperchlorina- ing facilities where laboratory-confirmed installed a UV treatment system for the 2017 tion of all public venues in the county, which persons indicated they swam in the 2 weeks swimming season. would not have been feasible. We recognize, before symptom onset or while ill proved This investigation had several limitations. however, that some venues that might have most acceptable and coincided with schools First, because cases were reported primar- been a source of exposure in cases were not reopening and a decline in incidence. The list ily through electronic laboratory reporting identified. Thus, public messaging did not of challenges regarding remediation of a rec- and active case finding was not performed, focus on implicating any individual venue, reational water-associated cryptosporidiosis numbers reported here likely underrepresent but emphasized that persons swimming at outbreak underscores the importance of pre- the scope of the outbreak. Previous studies any public venue during this period were at venting fecal contamination through the pro- have shown that cryptosporidiosis is severely increased risk for cryptosporidiosis. motion of healthy swimming behaviors. underreported (Painter et al., 2015) and the probable case definition in this outbreak Conclusion Acknowledgement: The authors would like required an epidemiologic link to a con- This large community-wide outbreak of cryp- to thank Brenna Garrett, Joli Weiss, and firmed case, which means that persons who tosporidiosis demonstrates the importance of Ken Komatsu of the Arizona Department of were ill but did not seek medical care were a multipronged response strategy, including Health Services; Kris Bisgard of CDC; and the not captured. Second, as is common with integration of exposure information obtained Arizona State Public Health Laboratory. late summer recreational water outbreaks, from interview responses with education for the timing of events—such as the concurrent the public and individual facilities. Although Corresponding Author: Rebecca Sunenshine, return of children to school, which reduces many different aquatic venues within Mari- Maricopa County Department of Public time for water recreation activities—presents copa County were affected in this outbreak, Health, 4041 North Central Avenue, Suite a challenge in measuring the impact of inter- public messaging and recommendations to 600, Phoenix, AZ 85012. ventions and remediation strategies. restrict water recreation likely prevented E-mail: [email protected].

References Bouzid, M., Hunter, P.R., Chalmers, R.M., & Tyler, K.M. (2013). Centers for Disease Control and Prevention. (2012). Promotion of Cryptosporidium pathogenicity and virulence. Clinical Microbiol- healthy swimming after a statewide outbreak of cryptosporidiosis ogy Reviews, 26(1), 115–134. associated with recreational water venues—Utah, 2008–2009. Causer, L.M., Handzel, T., Welch, P., Carr, M., Culp, D., Lucht, R., Morbidity and Mortality Weekly Report, 61(19), 348–352. . . . Dworkin, M.S. (2006). An outbreak of Cryptosporidium homi- Centers for Disease Control and Prevention. (2014). Creating the nis infection at an Illinois recreational waterpark. Epidemiology Model Aquatic Health Code (MAHC) (1st ed.). Retrieved from and Infection, 134(1), 147–156. https://www.cdc.gov/mahc/editions/previous.html Centers for Disease Control and Prevention. (2001). Protracted out- Centers for Disease Control and Prevention. (2016). Announce- breaks of cryptosporidiosis associated with swimming pool use— ment: Release of CDC’s 2016 Model Aquatic Health Code, sec- Ohio and Nebraska, 2000. Morbidity and Mortality Weekly Report, ond edition and revised hyperchlorination and fecal incident 50(20), 406–410. response recommendations. Morbidity and Mortality Weekly Centers for Disease Control and Prevention. (2007). Cryptosporidi- Report, 65(28), 720. osis outbreaks associated with recreational water use—Five states, Chappell, C.L., Okhuysen, P.C., Langer-Curry, R., Widmer, G., Aki- 2006. Morbidity and Mortality Weekly Report, 56(29), 729–732. yoshi, D.E., Tanriverdi, S., & Tzipori, S. (2006). Cryptosporidium Centers for Disease Control and Prevention. (2008). Communi- hominis: Experimental challenge of healthy adults. The American tywide cryptosporidiosis outbreak—Utah, 2007. Morbidity and Journal of Tropical Medicine and Hygiene, 75(5), 851–857. Mortality Weekly Report, 57(36), 989–993. Coetzee, N., Edeghere, O., Orendi, J., Chalmers, R., & Morgan, L. Centers for Disease Control and Prevention (2009). Outbreak of (2008). A swimming pool-associated outbreak of cryptosporidi- cryptosporidiosis associated with a splash park—Idaho, 2007. osis in Staffordshire, England, October to December 2007. Euro Morbidity and Mortality Weekly Report, 58(22), 615–618. Surveillance, 13(45), 1–3.

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References Cope, J.R., Prosser, A., Nowicki, S., Roberts, M.W., Roberts, J.M., Mathieu, E., Levy, D.A., Veverka, F. , Parrish, M.K., Sarisky, J., Sha- Scheer, D., . . . Hlavsa, M.C. (2015). Preventing community- piro, N., . . . Jones, J.L. (2004). Epidemiologic and environmen- wide transmission of Cryptosporidium: A proactive public tal investigation of a recreational water outbreak caused by two health response to a swimming pool-associated outbreak—Aug- genotypes of Cryptosporidium parvum in Ohio in 2000. American laize County, Ohio, USA. Epidemiology and Infection, 143(16), Journal of Tropical Medicine and Hygiene, 71(5), 582–589. 3459–3467. McCann, R., Jones, R., Snow, J., Cleary, P. , Burgess, S., Bothra, V. , Dufour, A.P., Evans, O., Behymer, T.D., & Cantú, R. (2006). Water & Chalmers, R.M. (2014). An outbreak of cryptosporidiosis at a ingestion during swimming activities in a pool: A pilot study. swimming club—Can rapid ﬁ eld epidemiology limit the spread of Journal of Water and Health, 4(4), 425–430. illness? Epidemiology and Infection, 142(1), 51–55. Fill, M.A., Lloyd, J., Chakraverty, T., Sweat, D., Manners, J., Garman, Murphy, J.L., Arrowood, M.J., Lu, X., Hlavsa, M.C., Beach, M.J., K., . . . Jones, T . F. (2017). Cryptosporidiosis outbreak associated & Hill, V.R. (2015). Effect of cyanuric acid on the inactivation with a single hotel. Journal of Environmental Health, 79(9), 16–22. of Cryptosporidium parvum under hyperchlorination conditions. Heymann, D.L. (Ed.). (2015). Cryptosporidiosis. In Control of com- Environmental Science & Technology, 49(12), 7348–7355. municable diseases manual (20th ed., pp. 136–139). Washington, Ng-Hublin, J.S., Hargrave, D., Combs, B., & Ryan, U. (2015). Inves- DC: American Public Health Association. tigation of a swimming pool-associated cryptosporidiosis out- Hlavsa, M.C., Roberts, V.A., Kahler, A.M., Hilborn, E.D., Mecher, break in the Kimberly region of Western Australia. Epidemiology T.R., Beach, M.J., . . . Yoder, J.S. (2015). Outbreaks of illness asso- and Infection, 143(5), 1037–1041. ciated with recreational water—United States, 2011–2012. Mor- Painter, JE., Hlavsa, M.C., Collier, S.A., Xiao, L., & Yoder, J.S. bidity and Mortality Weekly Report, 64(24), 668–672. (2015). Cryptosporidiosis surveillance—United States, 2011– Hlavsa, M.C., Roellig, D.M., Seabolt, M.H., Kahler, A.M., Murphy 2012. Morbidity and Mortality Weekly Report: Surveillance Sum- J.L., McKitt, T.K., . . . Xiao, L. (2017). Using molecular character- maries, 64(SS03), 1–14. ization to support investigations of aquatic facility-associated out- Puech, M.C., McAnulty, J.M., Lesjack, M., Shaw, N., Heron, L., & breaks of cryptosporidiosis—Alabama, Arizona, and Ohio, 2016. Watson, J.M. (2001). A statewide outbreak of cryptosporidiosis Morbidity and Mortality Weekly Report, 66(19), 493–497. in New South Wales associated with swimming at public pools. Joce, R.E., Bruce, J., Kiely, D., Noah, N.D., Dempster, W.B., Stalker, Epidemiology and Infection, 126(3), 389–396. R., . . . Watts, D. (1991). An outbreak of cryptosporidiosis associ- Shields, J.M., Hill, V.R., Arrowood, M.J., & Beach, M.J. (2008). Inac- ated with a swimming pool. Epidemiology and Infection, 107(3), tivation of Cryptosporidium parvum under chlorinated recreational 497–508. water conditions. Journal of Water and Health, 6(4), 513–520. Jokipii, L., & Jokipii, A.M. (1986). Timing of symptoms and oocyst Wheeler, C., Vugia, D.J., Thomas, G., Beach, M.J., Carnes, S., Maier, excretion in human cryptosporidiosis. The New England Journal of T., . . . Werner, S.B. (2007). Outbreak of cryptosporidiosis at a Medicine, 315(26), 1643–1647. California waterpark: Employee and patron roles and the long Lim, L.S., Varkey, P. , Giesen, P. , & Edmonson, L. (2004). Cryptospo- road towards prevention. Epidemiology and Infection, 135(2), ridiosis outbreak in a recreational swimming pool in Minnesota. 302–310. Journal of Environmental Health, 67(1), 16–20.

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 SPECIAL REPORT

Navigating Degrees of Collaboration: A Proposed Framework for Identifying Tiffany J. Huang, MPH, MA Department of Sociology and Implementing Health in Columbia University Bridget Kerner, MS National Association of County All Policies and City Health Officials Sandra Whitehead, PhD National Environmental Health Association

County and City Health Officials [NAC- CHO], 2017). At the state level, California’s Abstract As environmental health practice increasingly shifts HiAP Task Force works on a number of from a regulatory focus toward community-based approaches to prevention, environmental health initiatives, including more communities are adopting a Health in All Policies (HiAP) approach. healthy housing, air quality, climate change, This approach uses a systems approach to policy making to ensure that and green spaces (California Strategic policies have neutral or beneficial health impacts. As communities engage Growth Council, 2018). in cross-sector collaborations, however, the lack of a consistent vision and Identifying the Need for a Unifying defined role for environmental health professionals can limit implementation. Framework We address this challenge by proposing a framework for understanding the In 2015, the National Association of County various terms and methods used to describe HiAP efforts; we also identify and City Health Officials (NACCHO) under- roles for environmental health. Our framework begins with collaboration took a review of current HiAP efforts across the country, focusing specifically on local as the core of intersectoral work, then overlays other government-based governmental efforts. The authors of this and health-based approaches. HiAP sits at the final intersection of these evaluation updated an earlier literature elements. The resulting framework provides practitioners with a common review on HiAP (Gase, Pennotti, & Smith, language for working with partners, assessing current HiAP work, and 2013); interviewed state and local practi- planning and evaluating HiAP implementation. tioners who were implementing HiAP; and explored the themes, commonalities, and differences that distinguished their approaches (NACCHO, 2017). Two trends emerged from Introduction health and health equity” (WHO, 2014). This this work. As environmental health practice increas- practice uses a systems approach to ensure First, interest in HiAP has exploded in ingly shifts from a regulatory focus toward that policy making has neutral or beneficial recent years. Though the concept of “inter- community-based approaches to prevention, health impacts. sectoral collaboration for health” dates back more jurisdictions are adopting a Health in Environmental health professionals rou- to the 1978 WHO Declaration of Alma-Ata, All Policies (HiAP) approach. While the lit- tinely work with other sectors, so HiAP is HiAP has truly proliferated both nation- erature provides multiple definitions of HiAP, particularly relevant as a process that can ally and internationally in the past 15 years we use the definition provided by the World promote prevention-focused policies across (Rudolph, Caplan, Ben-Moshe, & Dil- Health Organization (WHO), which encom- sectors to improve health outcomes. As such, lon, 2013). As an illustration of this recent passes outcomes, purpose, and an ultimate environmental health professionals have growth, PubMed search results over time for goal: HiAP is “an approach to public policies played a key role in developing HiAP initia- “health in all policies” (quotations included) across sectors that systematically takes into tives. For example, the District of Colum- reveal only one article on the topic published account the health implications of decisions, bia’s HiAP taskforce is cochaired by the city’s in 2007, compared with 29 results in 2016. seeks synergies, and avoids harmful health Department of Health and Department of Nevertheless, research efforts remain rela- impacts, in order to improve population the Environment (National Association of tively nascent.

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“intersectoral action on health,” “social determinants of health,” and “cross-agency/ TABLE 1 cross-sector efforts.” Freiler and coauthors Two Spectrums of Collaboration (2013) propose a glossary in which HiAP implementation is framed as “a special case” Collaboration for a Change Health in All Policies: A Guide for State of intersectoral action. (Himmelman, 2002) and Local Governments Similarly, Kickbusch and Buckett (2010) (Rudolph, Caplan, Ben-Moshe, & Dillon, 2013) describe HiAP as part of a set of horizon- Networking: Exchanging information for Information exchange: Allows partners to gauge tal governance approaches that emerged in mutual benefit reactions, gain insight into other viewpoints, and waves, beginning in the late 1970s with “inter- allay controversy or conflict due to misinformation sectoral action,” then moving to “healthy Coordinating: Exchanging information and altering Consultation: Provides for more specific public policy,” and finally evolving as “HiAP.” activities for mutual benefit and to achieve a information gathering for improved decisions while common purpose explicitly reserving the decision-making prerogative Hendriks and coauthors (2014) summarize “definitions and goals of integrated public Cooperating: Exchanging information, altering Engagement: Implies a more active partnership activities, and sharing resources for mutual benefit including opportunities for partners and health policies or related notions with a simi- and to achieve a common purpose stakeholders to propose solutions and lar content, as proposed in the literature.” choose priorities These notions include “Health in All Poli- Collaborating: Exchanging information, altering Collaboration: Invites shared responsibility in cies,” “multisector policy,” “integrated health activities, sharing resources, and enhancing the decision making and implementation policy,” and “whole of government.” capacity of another for mutual benefit and to achieve a common purpose A Spectrum of Collaboration In the HiAP-related approaches that are The second trend is a lack of consis- ties understand each other’s roles and expecta- described in the literature, collaboration tency in defining HiAP, with researchers tions, including a common understanding of emerges as a unifying theme, with cross-sec- and practitioners offering varying descrip- underlying frameworks and nomenclature. tor relationship building serving as a key ele- tions of HiAP and similar concepts. No Inconsistency also hinders evaluation ment of HiAP practice (Association of State single framework has emerged as the gold efforts. If practitioners use the same term to and Territorial Health Officials [ASTHO], standard for implementation, in part due to describe a range of activities, evaluators can- 2013; NACCHO, 2014; Rudolph et al., the fragmented nature of the public health not accurately compare strategies and their 2013). In one guide, Rudolph and coauthors system within the U.S. This inconsistency outcomes. Evaluating HiAP’s effectiveness (2013) identify a “continuum of joint work- is not unique to HiAP work. The public thus becomes a “necessarily complex affair” ing relationships” that ranges from simple health field often deals with complex social (De Leeuw & Peters, 2015). For environ- “information exchange” to the more com- problems that require cross-sector collabo- mental health practitioners, rigorous evalu- prehensive “collaboration,” which “invites ration and multidisciplinary approaches to ation is needed to provide guidance on best shared responsibility in decision making and solve. Policy stakeholders often use differ- practices and implementation. implementation.” This spectrum recalls Him- ent terms for different audiences; they also In response to these trends in recent HiAP melman’s (2002) continuum of strategies for sometimes prefer abstract language that is work, we developed a framework for under- working together, which ranges from “net- more inclusive of competing interests and standing the variety of terms and methods working” to “collaboration.” Table 1 shows values (Hendriks et al., 2014). For example, that are currently being used to describe HiAP the differences and overlaps in the definitions health equity practitioners and researchers efforts. By identifying these approaches, we from these two sources. often preface their work by defining terms, provide environmental health practitioners such as “equity,” “equality,” “inequity,” and with a common language for working with A Model for Conceptualizing Health “disparity,” in order to clarify for the reader partners, as well as for planning, implemen- in All Policies how exactly they use each term. tation, and evaluation. Taking the above two themes together— Unfortunately, inconsistency can hamper that is, first, that HiAP is one of a variety of efforts at implementation, standardization, approaches with similar underlying princi- replication, and evaluation among partners Uniting the Elements of Health ples, and second, that collaboration, or some who disagree with or simply misunderstand in All Policies form of “working together,” is a common each other. For example, inconsistency can Previous authors have catalogued a variety element of these approaches—we propose lead to miscommunication if one party in a col- of HiAP terms. For example, Gase and coau- a model for defining HiAP that unites these laboration believes that “health equity” means thors (2013) identified approaches similar elements. We do not seek to replicate exist- ensuring equal access to healthcare services, to HiAP that they defined as “not explicitly” ing frameworks; instead, we aim to comple- while another party believes that it means HiAP, but rather approaches that “could be ment them by organizing abstract concepts in working on social determinants of health. considered a part of a HiAP ‘toolkit.’” These a way that is relevant for practitioners. The Successful collaborations require that all par- approaches included “healthy public policy,” result is a Venn diagram that both builds on

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the conceptualization of HiAP as one of a broader set of approaches and understands “working together” as the core of these FIGURE 1 approaches (Figure 1). Proposed Model for Defining Health in All Policies Our model begins with “collaboration,” a partnership of shared responsibility, which includes “exchanging information, altering Collaboration activities, sharing resources, and enhancing the capacity of another for mutual benefit and to achieve a common purpose” (NAC- CHO, 2014; Rudolph et al., 2013). Organi- Intersectoral Collaboration zational collaboration may occur between two private organizations, two governmental organizations, or in a private–public partner- Healthy Joined-Up ship. “Collaboration” in itself, however, is Public Policy Government Intersectoral insufficient to describe the other approaches Action for that are often discussed in relation to HiAP. Health Health in Whole of Collaboration does not require working All Policies Government across sectors and does not require goals specifically related to health. For example, the Natural Capital Project is an environmental partnership between academic institutions and nonprofit organizations that develops tools and resources to measure the natural An example of “intersectoral action for Pedestrian Council, an intergovernmen- environment’s contributions to society (Natu- health” is Livable Polk, a countywide effort tal body with the shared goal of promoting ral Capital Project, n.d.). The partnering orga- in Polk County, Florida. The partnership bicycle and pedestrian activity. The council is nizations collaborate to achieve the shared was originally led by the local public health sponsored by the state Department of Trans- goal of targeting investments in natural capi- and planning departments and encourages portation, but has members from several gov- tal. This collaboration takes place within the healthy living and well-being by chang- ernment agencies, including the Department environmental sector and does not specifically ing planning policies and encouraging sus- of Health and the Department of Environ- involve working toward improved health. tainable behaviors. The wider community mental Protection. Each agency has a vested In contrast, “intersectoral collaboration” is has adopted this approach and many of interest in encouraging the development of a particular type of collaborative activity that the resulting policies and programs relate infrastructure to support walking and biking explicitly involves working across sectors to the built environment. For example, the across the state, which includes promoting (Freiler et al., 2013). An example of inter- partnership has implemented a countywide health benefits (Florida Department of Trans- sectoral collaboration is the SmartWay Trans- Complete Streets policy that is intended to portation, 2018). port Partnership Program of the U.S. Envi- make streets safe and accessible for all users, As with “intersectoral collaboration,” the ronmental Protection Agency (U.S. EPA), in including pedestrians, bicyclists, and tran- term “joined-up government” can refer to which it works cross-sectorally with freight sit users (Smart Growth America, 2018). initiatives with goals other than improved shippers, carriers, and other stakeholders to Other initiatives include sponsorship of free health. When health is explicitly stated as the reduce the environmental impact of freight exercise classes in public parks, fresh food desired outcome, we use the term “healthy transportation (U.S. EPA, 2014). markets connected by walking trails, and a public policy.” Note that “policy” is defined While some use the term “intersectoral neighborhood-by-neighborhood approach to broadly to encompass not only laws and regu- action” to refer specifically to health-oriented mapping shared-use facilities (ASTHO, n.d.). lations but also decision making on program collaborations (e.g., Kickbusch & Buckett, The collaborative approaches defined up design, delivery, and prioritization (Rudolph 2010), we refrain from doing so here because to this point do not necessarily require gov- et al., 2013). our example clearly demonstrates that inter- ernmental involvement. A subset of collab- For example, the Arizona Alliance for Liv- sectoral collaboration can have nonhealth orative approaches, however, does explicitly able Communities, with input from the Mari- goals. Instead, when health is the explicit involve governmental entities. “Joined-up copa County Public Health Department, has goal, we use the term “intersectoral action for government” can be thought of as intersec- worked across the state to incorporate health health.” Here, the health sector works with toral collaboration specific to government, as a priority in several city general plans, one or more nonhealth sectors to address in which two or more governmental agencies which provide 10-year objectives and priori- health or the social determinants of health. collaborate to achieve a shared goal. ties for development. The City of Phoenix’s These approaches can be either governmental An example of a “joined-up government” general plan is one plan that has incorporated or nongovernmental. approach is Florida’s statewide Bicycle and health as a result of these efforts. Their plan

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TABLE 1 A Continuum of Collaborative Approaches and Characteristics

Approach Deﬁnition Characteristic

Collaboration Cross-Sector Health Governmental as a Goal Partner

Collaboration “Two or more parties or organizations working together to pursue Yes Optional Optional Optional new approaches that achieve goals that satisfy all engaged parties. In general, collaboration involves more than just an intersection of common goals, but actually working together to identify shared objectives” (Rudolph, Caplan, Ben-Moshe, & Dillon, 2013). Intersectoral “A recognized relationship . . . between different sectors of Yes Yes Optional Optional collaboration society working together in a way that can improve outcomes more effectively, efficiently, or sustainably than when working independently from one another” (Rudolph et al., 2013). “May occur across various levels of government and between governmental and nongovernmental sector [sic]” (Freiler et al., 2013). Intersectoral “Actions undertaken by sectors outside the health sector, in Yes Yes Yes Optional action for health collaboration with the health sector, on health or health equity outcomes, or on the determinants of health or health equity” (World Health Organization [WHO], 2014). Joined-up Involves the “use of institutions and structures of authority and Yes Yes Optional Yes government collaboration to allocate resources and coordinate and control joint (some action” (Carey, Crammond, & Keast, 2014). agencies) Healthy public “A policy or set of policies that is explicitly responsive to health Yes Yes Yes Yes policy needs. It may be designed specifically to promote health or, if not (some dealing directly with health, have an influence on the determinants agencies) of health and in turn positively impact health outcomes” (Rudolph et al., 2013). “Characterized by ‘an explicit concern for health and equity in all areas of policy, and by accountability for health impact’” (WHO, 1988, 2014). Whole of Includes public agencies “working across portfolio boundaries to Yes Yes Optional Yes government achieve a shared goal and an integrated government response to (all agencies) particular issues” (Commonwealth of Australia, 2004; Rudolph et al., 2013). Health in All “A collaborative approach that integrates and articulates health Yes Yes Yes Yes Policies considerations into policy making across sectors, and at all levels, (all agencies) to improve the health of all communities and people” (Association of State and Territorial Health Officials, 2013). “A collaborative approach to improving health that incorporates health considerations into decision making in all sectors and policy areas . . . convenes diverse partners to consider how their work influences health and how collaborative efforts can improve health while advancing other goals” (Rudolph et al., 2013). “An approach to public policies across sectors that systematically takes into account the health and health systems implications of decisions, seeks synergies, and avoids harmful health impacts, in order to improve population health and health equity” (WHO, 2014).

contains a framework that describes three to these beneﬁts. This effort to collaborate and involves a coordinated response across “community beneﬁts” to be considered in across sectors and include health as a prior- all government sectors. For example, in 2016, city decision making: health, prosperity, and ity embodies “healthy public policy” (City of the Obama Administration announced that environment. Each subsection of the plan Phoenix, 2015). the Centers for Disease Control and Preven- describes how proposed goals, measures, “Whole of government” takes the “joined- tion (CDC) was taking a “whole of govern- principles, policies, and actions contribute up government” approach one step further ment” approach to preventing the spread

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of Zika (CDC, 2016). A U.S. Department of mal citywide resolution, embodies the HiAP Their model describes six stages of maturity Homeland Security spokesperson explained approach at the center of our framework of HiAP work. Agencies that have not recog- that the administration was working across (City of Chicago, 2016). nized the need for HiAP are at stage 0. Agen- federal agencies, as well as with state and Table 2 summarizes our effort to pro- cies first recognize the problem of health ineq- local governments, to coordinate their out- vide a framework for HiAP and parse each uities and HiAP as a potential solution, and break response. Their response plan identified approach’s defining characteristics. then consider HiAP actions. They begin to 12 departments and agencies that played key implement HiAP, then fully integrate and insti- roles in mitigating Zika’s impact. Several of Conclusion tutionalize HiAP. Each stage requires different the plan’s objectives included environmental management and organizational strategies. health strategies, such as vector control and Potential Uses of the Framework An agency can use our framework in con- environmental surveillance. This coordinated Our intent in proposing this framework is to junction with these recommendations by Storm effort leveraged resources and plans across and provide organizations with a practical way of and coauthors (2014) to evolve their efforts within each level of government (U.S. Depart- conceptualizing HiAP work and imagining toward HiAP. This work might not always ment of Health and Human Services, 2016). the range of possibilities that it offers. In this progress linearly and our proposed framework respect, using the framework can have sev- does not suggest a timeline. Nevertheless, it At the Center: Health in All Policies eral benefits. First, our framework provides emphasizes that these approaches represent a Finally, a “whole of government” approach, a common language for understanding dif- continuum and that HiAP is a process by which with improved public health as the goal of ferent types of collaboration, with improved public health goals can be achieved—but is not intersectoral action, is what we refer to as population health as the goal. As noted earlier, necessarily an endpoint in itself. “Health in All Policies.” HiAP represents ambiguity can hamper HiAP implementation Finally, this framework could also be used in a coordinated, integrated approach across and communication across organizations comparative research across jurisdictions. Pub- both health and nonhealth sectors. The chief and sectors. By providing clear parameters of lic health researchers recognize the need for actors are typically governmental, but non- what each of these efforts entails, our frame- long-term evaluations to support HiAP imple- governmental agencies may also be involved. work can help organizations ensure that all mentation (Bert, Scaioli, Gualano, & Siliquini, For example, the City of Chicago’s HiAP partners involved in a collective effort are 2015; Ollila, 2011; Rantala, Bortz, & Armada, work officially began in 2011 when Mayor speaking the same language. 2014; Shankardass, Renahy, Muntaner, & Rahm Emanuel and Department of Pub- For environmental health professionals, O’Campo, 2015). As noted in the introduction lic Health Commissioner Bechara Choucair our examples demonstrate that they can play of this special report, however, evaluation is introduced Healthy Chicago: A Public Health crucial roles in collaborative efforts across a difficult without the ability to compare efforts Agenda for a Healthy City. The agenda iden- range of program areas. From simple bilateral across HiAP initiatives (De Leeuw & Peters, tified 12 priorities for public health improve- partnerships to comprehensive HiAP coali- 2015). As a next step, evaluators could apply ment, and included community engagement tions, public health departments can work this framework to enable robust comparisons and outreach strategies. In addition, the with a variety of organizations to achieve across different approaches. Healthy Chicago Interagency Council was cre- common goals in areas such as improving the ated to “leverage all city agency missions to built environment, chronic disease manage- Limitations improve public health, work collectively on ment, and vectorborne disease control. The development of this framework included policy change, allow for project specific part- Organizations can use our framework to some key limitations. First, inherent in the nerships, and stress the public health impacts assess the current state of their partnerships ambiguity described in the introduction, of each agency’s work” (Polsky, Stagg, Gakh, with both governmental and nongovernmental assessing the spectrum of HiAP approaches & Bozlak, 2015). This interagency council agencies, and consider how to evolve their exist- can be difficult when communities use dif- has facilitated intersectoral partnerships to ing work. For example, a public health agency ferent terminology to describe their work. address issues such as food access. that is interested in HiAP might find that their In several of our examples, communities Recently, Chicago’s city council passed a current collaborative activities focus primarily incorporated health into their decision mak- resolution to formalize their ongoing HiAP on same-sector partnerships. In this case, an ing without labeling their approach. In these efforts. While HiAP practice does not require effective next step could be to develop partner- cases, we extrapolated based on program a formal legislative instrument, it can insti- ships outside of the public health sector. Alter- or policy descriptions. The very goal of our tutionalize a jurisdiction’s intent and help nately, a local municipality might find that they framework is to help address this limitation provide an accountability structure (NAC- already use a whole-of-government approach to in HiAP research and practice by clarifying CHO, 2014). Chicago’s resolution created a advance nonhealth goals, such as community terms and definitions. citywide HiAP Task Force, which will work economic development. Their next step could A second limitation is the relative dearth to ensure that health is considered in all gov- be to incorporate health goals into their exist- of HiAP examples specific to governmental ernment decision making. Overall, the city’s ing whole-of-government partnership. public health in the U.S., despite an ongo- coordinated effort across health and non- In this vein, Storm and coauthors (2014) ing rise in popularity. Although more recent health sectors of government, coupled with propose a useful maturity model that can publications describe U.S. efforts such as an extensive engagement strategy and for- help an agency think through such planning. Chicago, Illinois; Richmond, California;

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and Washington, DC (Corburn, Curl, Arre- context. NACCHO’s 2017 publication, Health dan, formerly of NACCHO; and the journal dondo, & Malagon, 2014; Polsky et al., in All Policies: Experiences From Local Health reviewers for providing feedback on this 2015; Wernham & Teutsch, 2015), the vast Departments, hopes to address this limitation manuscript. Sandra Whitehead and Tiffany majority of published academic literature by providing a description of current HiAP ini- Huang also acknowledge support from NAC- describes HiAP in international contexts. tiatives led by or involving local health depart- CHO, where they conducted preliminary These international examples, including ments across the U.S. Ultimately, we hope that work on this project. longer-term evaluative efforts, provide valu- this framework is a useful tool for moving able information for U.S. practitioners. from HiAP theory to practice. Corresponding Author: Tiffany J. Huang, Differences in governmental capacity, infra- Department of Sociology, Columbia Univer- structure, governance structure, and politics, Acknowledgements: The authors wish to sity, 606 West 122nd Street, 5th Floor, New however, could prevent these case studies thank Hope Roobol of CDC’s National Cen- York, NY 10027. from being entirely applicable to the U.S. ter for Environmental Health; Megan Jour- E-mail: [email protected].

References Association of State and Territorial Health Officials. (2013). Health De Leeuw, E., & Peters, D. (2015). Nine questions to guide develop- in All Policies: Strategies to promote innovative leadership. Arling- ment and implementation of Health in All Policies. Health Promo- ton, VA: Author. Retrieved from http://www.astho.org/programs/ tion International, 30(4), 987–997. prevention/implementing-the-national-prevention-strategy/ Florida Department of Transportation. (2018). Florida Bicycle and hiap-toolkit/ Pedestrian Partnership. Retrieved from http://www.dot.state.fl.us/ Association of State and Territorial Health Officials. (n.d.). Inte- planning/policy/bikeped/ grating public health and planning in Florida. Arlington, VA: Freiler, A., Muntaner, C., Shankardass, K., Mah, C.L., Molnar, A., Author. Retrieved from http://www.astho.org/programs/health- Renahy, E., & O’Campo, P. (2013). Glossary for the implementa- in-all-policies/environmental-health-in-all-policies/environ tion of Health in All Policies (HiAP). Journal of Epidemiology and mental-health-in-all-policies-case-study-florida-planning/ Community Health, 67(12), 1068–1072. Bert, F., Scaioli, G., Gualano, M.R., & Siliquini, R. (2015). How can Gase, L.N., Pennotti, R., & Smith, K.D. (2013) “Health in All Poli- we bring public health in all policies? Strategies for healthy soci- cies”: Taking stock of emerging practices to incorporate health eties. Journal of Public Health Research, 4(1), 393. in decision making in the United States. Journal of Public Health California Strategic Growth Council. (2018). HiAP Task Force action Management and Practice, 19(6), 529–540. plans and reports. Retrieved from http://sgc.ca.gov/programs/hiap/ Hendriks, A.M., Habraken, J., Jansen, M.W., Gubbels, J.S., De Vries, resources/action-plans-reports.html N.K., van Oers, H., . . . Kremers, S.P. (2014). “Are we there yet?”— Carey, G., Crammond, B., & Keast, R. (2014). Creating change in Operationalizing the concept of integrated public health policies. government to address the social determinants of health: How can Health Policy, 114(2–3), 174–182. efforts be improved? BMC Public Health, 14, 1087. Himmelman, A.T. (2002). Collaboration for a change. Retrieved from Centers for Disease Control and Prevention. (2016). National http://depts.washington.edu/ccph/pdf_files/4achange.pdf Zika Summit focused on coordinated U.S. response [Press release]. Kickbusch, I., & Buckett, K. (Eds.). (2010). Implementing Health in Retrieved from http://www.cdc.gov/media/releases/2016/p0401-zika- All Policies: Adelaide 2010. Retrieved from http://www.who.int/sdh- summit.html conference/resources/implementinghiapadel-sahealth-100622.pdf City of Chicago. (2016). Mayor Emanuel’s “Health In All” resolution National Association of County and City Health Officials. (2014). to ensure that health of communities is at the core of all city policies Local health department strategies for implementing Health in All [Press release]. Retrieved from http://www.cityofchicago.org/city/ Policies. Washington, DC: Author. Retrieved from http://archived. en/depts/cdph/provdrs/healthychicago/news/2016/may/mayor- naccho.org/topics/environmental/hiap/upload/factsheet_hiap_ emanuel-s--health-in-all--resolution-to-ensure-that-health.html dec2014-1.pdf City of Phoenix. (2015). PlanPHX, 2015 general plan, city council National Association of County and City Health Officials. (2017). adopted version. Retrieved from https://www.phoenix.gov/pddsite/ Health in All Policies: Experiences from local health departments. Documents/PZ/pdd_pz_pdf_00451.pdf Washington, DC: Author. Retrieved from http://www.naccho.org/ Commonwealth of Australia, Australian Public Service Commission uploads/downloadable-resources/NACCHO-HiAP-Report_Expe- (2004). Connecting government: Whole of government responses riences-from-Local-Health-Departments-Feb-2017.pdf to Australia’s priority challenges. Canberra, Australia: Author. Natural Capital Project. (n.d.). Who we are. Retrieved from http://www. Retrieved from https://trove.nla.gov.au/version/45206367 naturalcapitalproject.org/what-is-natural-capital/#our-partners Corburn, J., Curl, S., Arredondo, G., & Malagon, J. (2014). Health Ollila, E. (2011). Health in All Policies: From rhetoric to action. in All Urban Policy: City services through the prism of health. Scandinavian Journal of Public Health, 39(Suppl. 6), 11–18. Journal of Urban Health, 91(4), 623–636. continued on page 28

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References continued from page 27 Polsky, C., Stagg, K., Gakh, M., & Bozlak, C.T. (2015). The Health U.S. Department of Health and Human Services. (2016). United in All Policies (HiAP) approach and the law: Preliminary lessons States government Zika virus disease contingency response plan. from California and Chicago. The Journal of Law, Medicine & Eth- Washington, DC: Author. Retrieved from https://www.phe.gov/ ics, 43(Suppl. 1), 52–55. Preparedness/planning/Documents/zika-response-plan2016.pdf Rantala, R., Bortz, M., & Armada, F. (2014). Intersectoral action: U.S. Environmental Protection Agency. (2014). U.S. Environmental Local governments promoting health. Health Promotion Interna- Protection Agency’s SmartWay Transport Partnership Program: Rec- tional, 29(Suppl. 1), i92–102. ommendations and ﬁndings. Washington, DC: Author. Retrieved Rudolph, L., Caplan, J., Ben-Moshe, K., & Dillon, L. (2013). Health from https://www.epa.gov/sites/production/ﬁles/2014-09/docu in All Policies: A guide for state and local governments. Washing- ments/smartway-wkgrp-report-042014.pdf ton, DC and Oakland, CA: American Public Health Association Wernham, A., & Teutsch, S.M. (2015). Health in All Policies for big and Public Health Institute. Retrieved from http://www.phi.org/ cities. Journal of Public Health Management and Practice, 21(Suppl. resources/?resource=hiapguide 1), S56–65. Shankardass, K., Renahy, E., Muntaner, C., & O’Campo, P. (2015). World Health Organization. (1988). Adelaide recommendations on Strengthening the implementation of Health in All Policies: A healthy public policy. Geneva, Switzerland: Author. Retrieved methodology for realist explanatory case studies. Health Policy from http://www.who.int/healthpromotion/conferences/previous/ and Planning, 30(4), 462–473. adelaide/en/ Smart Growth America. (2018). What are complete streets? World Health Organization. (2014). Health in All Policies Retrieved from https://smartgrowthamerica.org/program/national- (HiAP) framework for country action. Geneva, Switzerland: complete-streets-coalition/what-are-complete-streets/ Author. Retrieved from http://www.who.int/cardiovascular_ Storm, I., Harting, J., Stronks, K., & Schuit, A.J. (2014). Measuring diseases/140120HPRHiAPFramework.pdf stages of Health in All Policies on a local level: The applicability of a maturity model. Health Policy, 114(2–3), 183–191.

28 Volume 81 • Number 4

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TYLER’S DHD SOFTWARE STREAMLINES ENVIRONMENTAL HEALTH PROCESSES

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 BUILDING CAPACITY

Building Capacity Through Project Agility

Darryl Booth, MBA

once initiated, there’s no capacity to go back Editor’s Note: A need exists within environmental health agencies and redo (or even optimize) what was deliv- to increase their capacity to perform in an environment of diminishing ered. This method is known as Waterfall, a metaphor to illustrate the idea that once resources. With limited resources and increasing demands, we need to seek water—or in this case, project planning— new approaches to the business of environmental health. cascades beyond a certain milestone, there is Acutely aware of these challenges, NEHA has initiated a partnership no going back. Yet, even with Waterfall’s potential pitfalls, with Accela called Building Capacity. Building Capacity is a joint effort to most government procurement rules are educate, reinforce, and build upon successes within the profession, using wired to get the whole project (the require- technology to improve effi ciency and extend the impact of environmental ments, timeline, budget, and team) locked in health agencies. far in advance. In the April 2018 Journal of Environmental The Journal is pleased to publish this bimonthly column from Accela that Health (www.neha.org/node/59821), we pro- will provide readers with insight into the Building Capacity initiative, as well posed methods to hack your system imple- as be a conduit for fostering the capacity building of environmental health mentation. Agile takes these hacks to the next level and is steadily becoming the new agencies across the country. norm in local government. The conclusions of this column are those of the author(s) and do not At its essence, Agile means taking a project necessarily represent the views of NEHA. into smaller time-boxed subprojects. These Darryl Booth is senior vice president and general manager of environmental subprojects can be as short as 2 weeks, with each defined, completed, and potentially health at Accela and has been monitoring regulatory and data tracking delivered individually. Then subsequent needs of agencies across the U.S. for almost 20 years. He serves as technical iterations, naturally, refl ect the user feedback advisor to NEHA’s information and technology section. and priorities from the previous iterations. The expectation is that circumstances will change, priorities will shift, users will change their minds or become more in tune as they ou are an educated professional, a of any size and for reducing risk. The method observe work to date, and negative impacts leader, a driver of business and pro- is known as Agile. of any misjudgment are generally limited to Y cess improvement. You bring experi- Agile got its start in software development the smaller work periods. It’s wading into the ence and passion and intuition. In our pro- where—and at great effort—project require- swimming hole instead of diving. fessional lives, however, we’ve each certainly ments were routinely specifi ed in writing Figure 1 identifi es the component parts of observed or led projects that fl opped in part before programmers or users got a fi rst peek. each smaller iteration as projects are designed, or in full. When we run projects where half or more developed, tested, deployed, and reviewed. You might never lead a multimillion-dollar of our budget is spent writing requirements The whole project is bookended by planning software project, but you will lead or par- before our users are engaged, we bear the risk at the beginning and launch at the fi nish. ticipate in important projects. This column that the result won’t delight our users. Then, Do not think, however, of Agile only in introduces a method for approaching projects because these project budgets are often fi xed the context of software development. Terms

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product. Almost certainly she’ll use the entire timeline and budget (maybe more) and strive Agile Resources FIGURE 1 to hit every requirement conceived of the The Agile Diagram year before. • Agile Project Management: A Com- Angela Agile prehensive Guide: www.cio.com/ In an Agile mindset, Angela, a health depart- article/3156998/agile-development/ ment project manager, sits down with stake- agile-project-management-a-begin holders and builds a backlog of all the things ners-guide.html the department wants or needs. Those items • Scaling Agile in Government: https:// that might take longer than 2 weeks (the deloitte.wsj.com/cio/2018/08/17/ smallest work period to which the team scaling-agile-in-government-2 commits to) are divided into smaller tasks that will take less than 2 weeks. The list is • Agile by the Numbers: A Data Analy- ordered and can be augmented and reordered sis of Agile Development in the U.S. with each iteration. Nothing is fixed in stone. Federal Government: www2.deloitte. There’s no obligation to complete the entire com/insights/us/en/industry/public- list since some things might naturally fall off sector/agile-in-government-by-the- like deploy and launch apply to health inter- as not important. numbers.html ventions or placarding projects or fee pro- Angela’s deep understanding of the domain posals. In fact, the methodologies can be allows her to order the backlog to maximize applied to any project. I’ve used Agile for return on investment (ROI) and reduce risk. technical documentation, marketing cam- For example, one might say that designing Angela’s project exploits continuous learn- paigns, and even training. the placard has the highest priority because ing, taking on new requirements and remov- To illustrate further, let’s imagine a fic- it’s a tangible representation of what is being ing others. Small tasks and nimble teams tional scenario where a local health depart- proposed, useful in training, and requires expect continuous feedback from stakehold- ment applies Agile to a grading or placard- approval. On the other hand, if the plac- ers. The final product doesn’t look exactly ing project. ard design takes 2 months to complete, like what was originally envisioned—it looks costs $10,000, and the board of supervisors better! The team discovered that there was no Fictional Scenario: Great Health declines the necessary ordinance change, the need for an ordinance change and that they County Launches Placarding for $10,000 and the time are lost. could easily clone and tweak a neighboring Retail Food Facilities Instead, Angela might create and prioritize health department’s design, training materi- a smaller task such as “collect existing placard als, and any other relevant components. The Whitney Waterfall design from neighboring health departments savings allowed for more outreach and a hap- In a Waterfall mindset, Whitney, a health as likely representations of what our commu- pier customer. department project manager, meets with nity has already embraced.” The cost is nearly stakeholders and plans the entire project zero but the task still facilitates the proposal, Conclusions and Next Steps from initiation to a 1-year, post-implemen- training, and communications and outreach. Short bursts of tangible deliverables are ener- tation assessment. All the tasks—which- Angela forms a small team (just those gizing to teams. The license to freely recon- might include outreach, ordinance, board people likely needed for the several items at sider (i.e., add or remove) the requirements approval, research, system design, placard the top of the ordered backlog) and the team mitigates tough conversations about making design, printing, training, communications, decides how much work they can accomplish compromises. And finally, the overt focus on launch, and a 1-year assessment—are listed and deliver in 2 weeks. customer satisfaction is very rewarding for all. end-to-end (perhaps with some overlap). The team meets daily for a very short stand- Review the additional resources in the She’s proud of her Gantt chart and makes a up meeting to convey what was completed sidebar and let’s see if Agile has a place in proposal to the health officer. The project is yesterday, what activities will be completed your next project. Continue the conversation green-lighted, resources are assigned, and the this day, and what, if anything, is holding the in the Building Capacity in Environmental project kicks off with regular hour-long sta- team back. If one team member finishes early, Health Group on LinkedIn (www.linkedin. tus meetings where the fixed plan is updated they jump in to help others. If the team com- com/groups/6945520). with status changes, slippage, etc. The meet- pletes its commitments early, the team adds ings usually run long. items from the ordered backlog. At the end of Corresponding Author: Darryl Booth, Senior Whitney’s project proceeds as similar proj- the work period, the team reconvenes, deliv- Vice President and General Manager of Envi- ects do, with some setbacks and some suc- ers its work product, and Angela augments or ronmental Health, Accela, 2633 Camino cesses, some scheduling challenges, some reorders the list for the next work period. In Ramon #500, San Ramon, CA 94583. resourcing problems, and (hopefully) a final this way, the project proceeds iteratively. E-mail: [email protected].

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 DIRECT FROM ATSDR

Investigating Hazardous Substance Exposures Associated With Mining or Smelting in United States Communities

LCDR Mateusz Karwowski, MPH, MD

or former mining or smelting sites. Com- Editor’s Note: As part of our continued effort to highlight innovative mon themes were identifi ed through review of fi nal reports and unstructured interviews approaches to improve the health and environment of communities, the with staff who led or participated in the EIs. Journal is pleased to publish a bimonthly column from the Agency for Four EI sites met inclusion criteria (Table Toxic Substances and Disease Registry (ATSDR) at the Centers for Disease 1). All sites were located in rural areas and three were in the Mountain States. One site Control and Prevention (CDC). ATSDR serves the public by using the best had ongoing mining and smelting activity. science, taking responsive public health actions, and providing trusted Environmental sampling revealed elevated health information to prevent harmful exposures and diseases related concentrations of heavy metals in air, soil, and/or water at all sites, with the most com- to toxic substances. The purpose of this column is to inform readers of mon contaminants being arsenic and lead. ATSDR’s activities and initiatives to better understand the relationship The primary routes of exposure were inha- between exposure to hazardous substances in the environment, its impact lation and ingestion. Vulnerable populations identifi ed during the investigations included on human health, and how to protect public health. children, women of childbearing age, preg- The conclusions of this column are those of the author(s) and do not nant women, and persons with certain preex- isting medical conditions. necessarily represent the offi cial position of ATSDR or CDC. Investigators employed a variety of strat- LCDR Mateusz (Matt) Karwowski is an offi cer in the U.S. Public Health egies to overcome common barriers across Service and a senior medical offi cer and epidemiologist on ATSDR’s Exposure sites, examples of which included scarce public health and community resources, Investigations Team. He is currently coleading ATSDR’s multisite per- and socioeconomic disadvantage, and lack of polyfl uoroalkyl substances (PFAS) exposure assessment work. stakeholder interest. Community engagement before, during, and after investigations was instrumental in promoting awareness, participation, and trust in ATSDR’s fi ndings. ommunities across the U.S. face po- The Agency for Toxic Substances and Dis- Effective communication strategies included tential exposures to hazardous sub- ease Registry (ATSDR) partners with govern- hosting community meetings, conducting C stances that originate from a variety ment, academic, and community organiza- outreach through local media, and meeting of sources including active and historic in- tions to conduct hazardous waste exposure individually with concerned citizens. Partner- dustrial facilities and hazardous waste sites. investigations (EIs) in U.S. communities. By ing with state and local offi cials, community For communities living near sites associated characterizing environmental exposures to leaders, school administrators, medical pro- with current or former mining or smelting community members, ATSDR provides critical fessionals, and other infl uential community operations, residents are at risk of exposure information to stakeholders that guides public members helped EI teams overcome logisti- to toxic metals that have the potential to health action, including risk mitigation. cal and other challenges. Finally, multiagency harm human health (Eckel, Rabinowitz, & This column describes common themes collaboration in which roles were clearly Foster, 2001; U.S. Environmental Protection and highlights best practices from ATSDR defi ned facilitated protocol implementation Agency, 2018). EIs conducted between 2010–2017 at current and the generation of timely reports.

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TABLE 1 Agency for Toxic Substances and Disease Registry Exposure Investigation Sites Associated With Mining or Smelting Activities, United States, 2010–2017

Flat Creek Iron Colorado Asarco Hayden Former United Mountain Mine Smelterb Smelter Plantc Zinc and and Milla Associated Smeltersd

Location Superior, Montana Pueblo, Colorado Hayden and As of 2013, a slag pile measuring an estimated Iola, Kansas 3 Winkelman, 21 million ft and containing hazardous levels of Arizona arsenic and lead sat within 200 ft of residences in Pueblo, Colorado. Photo courtesy of the Agency for Toxic Substances and Disease Registry. Population within 893e 3,830e 662 (Hayden)f 5,875f area of concern 353 (Winkelman)f successful grant application for $5 million to Dates of on-site July 2010 September and April 2015 December 2016 investigation November 2013 and October 2017 mitigate environmental hazards. ATSDR exposure investigations provide a Site history Mine: 1888–1954 Smelter: Mine: 1880– Smelter: valuable service to communities whose expo- 1883–1908 present 1902–1925 sure to contaminants from neighboring NPL Smelter: 1912– sites is incompletely understood. Investiga- present tions that prioritize community engagement, partnership, and multiagency collaboration Contaminants Antimony, arsenic, Arsenic and lead Arsenic, cadmium, Arsenic and lead are most likely to succeed in delivering mean- and lead chromium, copper, and lead ingful results to stakeholders. By informing and supporting the need for community-level U.S. NPL: September NPL: December Superfund NPL: May 2013 public health interventions, ﬁndings from Environmental 2009 2014 Alternative exposure investigations have the potential to Protection Process: generate public health beneﬁts for communi- Agency National Preliminary ties beyond their primary goal of exposure Priorities List assessment in (NPL) status 1988g characterization.

aHealth Consultation: Exposure Investigation, Biological Monitoring for Exposure to Lead and Arsenic, Superior, Mineral Corresponding Author: Mateusz Karwowski, County, Montana (www.atsdr.cdc.gov/HAC/pha/SuperiorMTEIReport/SuperiorMTHCEIReport03312011.pdf). LCDR, U.S. Public Health Service, Senior bHealth Consultation: Exposure Investigation, Biological Testing for Exposure to Lead and Arsenic Near Colorado Smelter Medical Officer and Epidemiologist, Division (www.atsdr.cdc.gov/HAC/pha/ColoradoSmelter/ColoradoSmelter_%20HC-EI%20(final)_%2009-10-2015_508.pdf). of Community Health Investigations, Agency cHealth Consultation: Exposure Investigation, Biological Testing for Exposure to Lead and Arsenic Near Asarco Hayden Smelter for Toxic Substances and Disease Registry, Site (www.atsdr.cdc.gov/HAC/pha/AsarcoHaydenSmelterSite/AsarcoHaydenSmelterSite_HC_EI_03272017_508.pdf). 4770 Buford Highway NE, MS F-59, Atlanta, dHealth Consultation: Exposure Investigation, Biological Testing for Exposure to Lead, Former United Zinc & Associated Smelters (www.atsdr.cdc.gov/HAC/pha/FormerUnitedZinc/Former_United_Zinc_EI-508.pdf). GA 30341. E-mail: [email protected]. e2000 U.S. Census. f2010 U.S. Census. References gDraft Report: Remedial Investigation Report for the ASARCO LLC Hayden Plant Site (https://semspub.epa.gov/ Eckel, W.P., Rabinowitz, M.B., & Foster, work/09/100005516.pdf). G.D. (2001). Discovering unrecognized lead-smelting sites by historical methods. American Journal of Public Health, 91(4), 625–627. Though the primary purpose of EIs is to ing residential lead inspections at one site U.S. Environmental Protection Agency. (2018). provide information on human exposure to and follow-up biomonitoring at another. Superfund: National Priorities List (NPL). hazardous substances, examples from these One community used biomonitoring results Retrieved from https://www.epa.gov/super investigations demonstrate their potential to guide their decision on whether to pur- fund/superfund-national-priorities-list-npl to impact public health beyond characteriz- sue having their site listed on the National ing human exposure. EI findings stimulated Priorities List (NPL). In another example, public health surveillance activities includ- biomonitoring results were used to support a

November 2018 • Journal of Environmental Health 33

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 DIRECT FROM CDC ENVIRONMENTAL HEALTH SERVICES

Now What? A Tool to Help Commercial Fishermen Encountering Sea-Disposed Chemical Munitions

CDR Danielle Shirk Mills, MPH, RS/REHS, GA-CEM, EMHP

ways on the eastern shore of Delaware in Editor’s Note: NEHA strives to provide up-to-date and relevant 2004. A military explosive ordnance dis- information on environmental health and to build partnerships in the posal (EOD) technician developed substantial blistering (Photo 2) after responding to profession. In pursuit of these goals, we feature this column on environmental an incident off base in which an unknown health services from the Centers for Disease Control and Prevention (CDC) projectile was recovered and destroyed by in every issue of the Journal. detonation (Fendick et al., 2013). In these columns, authors from CDC’s Water, Food, and Environmental In 2010, commercial ﬁ shermen recovered an

Health Services Branch, as well as guest authors, will share insights and unknown number of munitions while dredg-

PRACTICE

ing for clams off the coast of Long Island, New ADVANCEMENT OF THE information about environmental health programs, trends, issues, and York. During the effort to dump the munitions resources. The conclusions in these columns are those of the author(s) and back in the ocean, a munition fell on the deck do not necessarily represent the offi cial position of CDC. of the boat, releasing a black liquid substance. CDR Danielle Mills is an environmental health and industrial hygiene Drops of the substance also landed on the subject matter expert providing oversight to the U.S. Army’s destruction of clothing covering the leg and arm of a crew member. After several hours, two crew mem- chemical weapons. She works in CDC’s National Center for Environmental bers felt ill and were transported to a local Health, Division of Environmental Health Science and Practice, Chemical hospital for evaluation. One was evaluated Weapons Elimination Branch. and released, while the other developed small blisters on his forearm and upper thigh. These injuries were recognized as sulfur mustard efore the 1970s, disposal of excess, mental health practitioners, especially those exposure by a nurse trained in chemical agent obsolete, or unserviceable munitions along coastal areas, should be aware that injuries. Exposure was confi rmed by chemical B at sea was common. (Photo 1). It was these incidents are occurring. Since 2004, analysis (Fendick et al., 2013). believed that the vastness of ocean waters the Centers for Disease Control and Preven- In 2012, a 75-mm projectile was recovered would neutralize chemical agents that might tion (CDC) has been notifi ed of several inci- at a clam processing plant in Delaware. It have leaked from these weapons. Sea-disposal dents in which personnel were exposed to was reportedly brought to the plant acciden- operations included the disposal of conven- chemical agents associated with recovered tally during dredging operations for clams tional munitions of every type and chemical sea-disposed chemical munitions. Several in Delaware Bay. An EOD team removed the munitions with various chemical agent fi lls. of the reported incidents resulted in toxic munition for disposal. The munition con- Commercial fi shing, clamming, and dredging chemical agent contamination/injuries to tained mustard agent. None of the potentially operations can stir up these munitions and workers involved in commercial clam fi sh- exposed persons developed signs or symp- they can be encountered anywhere at sea, not ing operations. All incidents involved World toms of exposure to mustard. Clam fi sher- just charted hazardous areas. War I-era blister agents recovered from pre- men told investigators that they routinely There is now increasing concern about viously unknown sea disposal locations off recover munitions that often “smell like environmental and human health effects the U.S. East Coast. The fi rst incident was garlic,” a potential indication of a chemical associated with the disposal of these agents the result of harvesting clamshells for the agent (Massachusetts Department of Envi- both on land and in the ocean. Environ- use as aggregate in concrete and for drive- ronmental Protection, 2010).

34 Volume 81 • Number 4

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Photo 2. Image of the burns to the hand of an explosive ordnance disposal airman exposed to mustard in 2004. Photo courtesy of the U.S. Army.

Photo 3. An unrecognizable munition brought up during ocean ﬂoor dredging. Photo courtesy Photo 1. Conducting sea disposal operations. Photo courtesy of the U.S. Army. of the U.S. Army.

In 2016, an ocean clammer was sorting chemical munitions are encountered. It lays Hygienist, Chem Demil/Emergency Manage- through clams on an ocean clamming vessel out a sequence of personal protection, dis- ment, Radiation, and Chemical Branch, Divi- and was exposed to a liquid-like substance posal, and after-event monitoring. The tool sion of Environmental Health Science and while dislodging a rock or object that had also provides guidance regarding what to do Practice, National Center for Environmental clogged the hopper of the vessel. He developed starting from the point that a munition is in- Health, Centers for Disease Control and Pre- blistering symptoms but did not present to a advertently brought aboard. The tool concise- vention, 4770 Buford Highway NE, MS F-61, medical care center until 36 hr later. Due to ly covers four things important to protecting Atlanta, GA 30341-3717. his significant burns—reportedly 7–8% of the the health of fishermen who could encoun- E-mail: [email protected]. skin surface on his shoulder and arms—he was ter these munitions: 1) disposal overview, 2) transferred to a burn unit in Philadelphia where protective equipment donning and doffing, References the injury was recognized as a burn consistent 3) nine-step emergency disposal procedure, Fendick, R., King, J., Tincher, T., Radke, with mustard exposure (The Maritime Execu- and 4) symptoms and healthcare provider M., Begluitti, G., Cruz, M., . . . Delaney, tive, 2016). In 2017, a fisherman was exposed card. It even includes a “take me with you L. (2013). Exposures to discarded sulfur to a suspected chemical warfare agent in an to your healthcare provider” card with use- mustard munitions—Mid-Atlantic and event that closely mirrored the 2016 event. ful information about signs, symptoms, and New England States 2004–2012. Morbid- CDC has concerns for the health of fisher- chemical testing. ity and Mortality Weekly Report, 62(16), men who might be exposed when munitions The tool can be found at www.cdc.gov/ 315–316. are dredged up with clams and other bottom nceh/demil. Next steps include preparing The Maritime Executive. (2016, August 12). dwelling sea life (Photo 3). CDC started an personal protective equipment (PPE) kits Clam fisherman dredges up chemical weapons. interest group for stakeholders, including and training resources for fishermen, as well Retrieved from https://www.maritime-exec- the U.S. Coast Guard and federal and state as for medical providers who could treat the utive.com/article/clam-fisherman-dredges- departments of health and environment, to resulting exposures. The expanding use of up-chemical-weapons#gs.9pkPPwE discuss responses to these incidents and help the world’s oceans, and particularly its coastal Massachusetts Department of Environmen- improve future responses. The goals were to zones, requires not only an increased aware- tal Protection. (2010). MassDEP Field protect fishermen, improve recognition in ness of both chemical and conventional mu- Assessment and Support Team (FAST): After treatment facilities, and improve the public nitions in the sea but also increased response incident report, New Bedford clam contami- health network notification. and medical treatment capabilities. nation incident. Retrieved from http:// Working with interest group partners, www.mass.gov/eea/docs/dep/cleanup/ CDC recently introduced a new tool for the Corresponding Author: Danielle Shirk Mills, sites/nb610.pdf fishing industry designed to be helpful when CDR, U.S. Public Health Service, Industrial

November 2018 • Journal of Environmental Health 35

JEH11.18_PRINT.indd 35 10/4/18 3:10 PM ADVANCEMENT OF THE PRACTITIONER CAREER OPPORTUNITIES Food Safety Inspector UL Everclean is a leader in retail inspections. We offer opportunities across the country. We currently have openings for trained professionals to conduct audits in restaurants and grocery stores. Past or current food safety inspection experience is required. United States Buffalo, NY Grand Rapids, MI Missoula, MT Rapid City, SD Tulsa, OK Albany, NY Cedar Rapids, IA Harrisburg, PA Montgomery, AL Richmond, VA Wichita, KS Albuquerque, NM Charleston, SC Honolulu, HI Oakland, CA Rochester, NY Yuma, AZ Allentown, PA Chicago, IL Houston, TX Odessa, TX Saint Louis, MO Canada Amarillo, TX Coeur d’Alene, ID Idaho Falls, ID Orlando, FL San Pedro, CA British Columbia Anaheim, CA Corpus Christi, TX Little Rock, AR Owatonna, MN Santa Maria, CA Calgary Bakersﬁ eld, CA Eugene, OR Long Beach, CA Pasadena, CA Santa Monica, CA Montreal Billings, MT Eureka, CA Los Angeles, CA Philadelphia, PA Seattle, WA Toronto Birmingham, AL Fresno, CA Lubbock, TX Phoenix, AZ Shreveport, LA Vancouver Boise, ID Galveston, TX Miami, FL Portland, OR Sioux Falls, SD Winnipeg Boston, MA Grand Junction, CO Midland, TX Providence, RI Syracuse, NY If you are interested in an opportunity near you, please send your resume to ATTN: Sethany Dogra at [email protected] or visit our website at www.evercleanservices.com.

You can stay in the loop everyday with NEHA’s social media presence. Find NEHA at Did You • Facebook: www.facebook.com/NEHA.org • Twitter: https://twitter.com/nehaorg • LinkedIn: www.linkedin.com/company/national-environmental-health-association Know? Follow us, like us, and join in on the conversation!

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36 Volume 81 • Number 4

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Where the “best of the best” consult...

NEHA’s Career Center

First job listing FREE for city, county, and state health departments with a NEHA member, and for Educational and Sustaining members.

For more information, please visit neha.org/professional- development/careers

THANK YOU for Supporting the NEHA/AAS Scholarship Fund

American Academy Priscilla Oliver, PhD of Sanitarians Atlanta, GA Lawrenceville, GA Vince Radke, MPH, RS, James J. Balsamo, Jr., CP-FS, DLAAS, CPH MS, MPH, MHA, Altanta, GA RS, CP-FS Richard L. Roberts Metairie, LA Grover Beach, CA LeGrande G. Beatson Leon Vinci, DHA, RS Farmville, VA Did You Know? Roanoke, VA George A. Morris, RS NEHA’s new membership structure includes ﬁ ve different Dousman, WI membership categories—Professional, Emerging Professional, Retired Professional, International, and Life. All members within these categories will receive the electronic version of the Journal. To donate, visit www.neha.org/ Members based in the U.S. also have the option to purchase a about-neha/donate/nehaaas-scholar print subscription of the Journal for just $35. Learn more at www. ship-program. neha.org/membership-communities.?

November 2018 • Journal of Environmental Health 37

JEH11.18_PRINT.indd 37 10/4/18 3:10 PM ADVANCEMENT OF THE PRACTITIONER EH CALENDAR

UPCOMING NEHA CONFERENCES Illinois November 5–6, 2018: Annual Educational Conference, hosted July 9–12, 2019: NEHA 2019 Annual Educational Conference by the Illinois Environmental Health Association, Oglesby, IL. & Exhibition, Nashville, TN. For more information, visit For more information, visit http://iehaonline.org. www.neha.org/aec. Kentucky July 13–16, 2020: NEHA 2020 Annual Educational Conference February 11–13, 2019: Annual Conference, hosted by the & Exhibition, New York, NY. Kentucky Environmental Health Association, Lexington, KY. For more information, visit http://kyeha.org/events. July 12–15, 2021: NEHA 2021 Annual Educational Conference & Exhibition, Spokane, WA. Maryland November 1, 2018: Fall Educational Conference, hosted by the National Capital Area Environmental Health Association, College NEHA AFFILIATE AND REGIONAL LISTINGS Park, MD. For more information, visit www.ncaeha.org.

Florida Ohio July 30–August 2, 2019: Annual Education Meeting, hosted April 11–12, 2019: 73rd Annual Educational Conference, by the Florida Environmental Health Association, Howey in the hosted by the Ohio Environmental Health Association, Hills, FL. For more information, visit www.feha.org/events. Worthington, OH. For more information, visit www.ohioeha.org. Idaho TOPICAL LISTING March 12–14, 2019: Annual Education Conference, hosted by the Idaho Environmental Health Association, Boise, ID. For more Public Health information, visit https://ieha-idaho.com. April 23–24, 2019: Iowa Governor’s Conference on Public Health, Des Moines, IA. For more information, visit www.ieha.net/IGCPH.

You can share your event with the environmental health community by Did You posting it directly on NEHA’s community calendar at www.neha.org/news- events/community-calendar. Posting is easy (and free) and is a great way to bring attention to your event. You can also ﬁ nd listings for upcoming Know? conferences and webinars? from NEHA and other organizations.

Join the growing ranks of professionals who have attained NEHA’s most in- demand credentials in food safety. Whether your focus is retail foodservice CP-FS/CCFS or food manufacturing and processing, NEHA’s Certiﬁ ed Professional—Food Safety (CP-FS) and Certiﬁ ed in Comprehensive Food Safety (CCFS) credentials demonstrate you went the extra mile to get specialized knowledge and training in food safety. Give yourself the edge that is quickly being recognized, required, and rewarded in the food industry. Learn more at neha.org/professional-development/credentials.

A credential today can improve all your tomorrows.

38 Volume 81 • Number 4

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announces

THE 2019 AEHAP STUDENT RESEARCH COMPETITION for undergraduate and graduate students enrolled in a National Environmental Health Science & Protection Accreditation Council (EHAC)-accredited program or an environmental health program that is an institutional member of AEHAP.

Entries must be submitted by Thursday, February 28, 2019, to Win a $1,000 Award Dr. Clint Pinion and up to $1,000 in travel expenses Eastern Kentucky University E-mail: [email protected] Students will be selected to present a 20-minute Phone: (859) 622-6330 platform presentation and poster at the National For additional information and research submission guidelines, Environmental Health Association’s Annual please visit www.aehap.org/internships.html. AEHAP gratefully acknowledges the volunteer efforts of Educational Conference & Exhibition in Nashville, AEHAP members who serve on the advisory committee Tennessee, July 9–12, 2019. for this competition. Opportunity for Students From EHAC-Accredited Environmental Health Degree Programs to Win a $3,500 PAID INTERNSHIP

The Association of Environmental Health Academic Programs (AEHAP), in partnership with NSF International, is offering a Application deadline: December 14, 2018 paid internship project to students from National Environmental Health Science & Protection Accreditation Council (EHAC)- accredited programs. The NSF International Scholarship Program is a great opportunity for an undergraduate student For more details and information on how to apply please to gain valuable experience in the environmental health field. go to www.aehap.org/internships.html. The NSF Scholar will be selected by AEHAP and will spend 8–10 For more information, contact [email protected] weeks (February–May 2019) working on a research project or call (859) 622-6330. identified by NSF International. Project Description The applicant shall work with a professor from their degree program who will serve as a mentor/supervisor and agree to providing a host location from which to do the research. Research will focus on evaluating the use and value of NSF standards and certified food equipment.

November 2018 • Journal of Environmental Health 39

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Resource Corner highlights different resources that NEHA has available to meet your education and training needs. These timely resources provide you with information and knowledge to advance your professional development. Visit NEHA’s online Bookstore for additional information about these, and many other, pertinent resources!

Handbook of Environmental Health, Volume 1: REHS/RS Study Guide (4th Edition) Biological, Chemical, and Physical Agents of National Environmental Health Association (2014) Environmentally Related Disease (4th Edition) The Registered Environmental Health Herman Koren and Michael Bisesi (2003) Specialist/Registered Sanitarian (REHS/RS) A must for the reference library of anyone in the credential is NEHA’s premier credential. This environmental health profession, this book focuses study guide provides a tool for individuals on factors that are generally associated with the to prepare for the REHS/RS exam and has internal environment. It was written by experts in been revised and updated to reflect changes the field and copublished with the National and advancements in technologies and Environmental Health Association. A variety of theories in the environmental health and environmental issues are covered such as food safety, protection field. The study guide covers the food technology, insect and rodent control, indoor air quality, following topic areas: general environmental health; statutes and hospital environment, home environment, injury control, pesticides, regulations; food protection; potable water; wastewater; solid and industrial hygiene, instrumentation, and much more. Environmental hazardous waste; zoonoses, vectors, pests, and poisonous plants; issues, energy, practical microbiology and chemistry, risk assessment, radiation protection; occupational safety and health; air quality; emerging infectious diseases, laws, toxicology, epidemiology, human environmental noise; housing sanitation; institutions and licensed physiology, and the effects of the environment on humans are also establishments; swimming pools and recreational facilities; and covered. Study reference for NEHA’s Registered Environmental disaster sanitation. Health Specialist/Registered Sanitarian credential exam. 308 pages / Paperback 790 pages / Hardback Member: $149 / Nonmember: $179 Volume 1: Member: $195 / Nonmember: $215 Two-Volume Set: Member: $349 / Nonmember: $379 Control of Communicable Diseases Manual (20th Edition) Handbook of Environmental Health, Volume 2: Edited by David L. Heymann, MD (2015) Pollutant Interactions With Air, Water, and Soil The Control of Communicable Diseases (4th Edition) Manual (CCDM) is revised and republished Herman Koren and Michael Bisesi (2003) every several years to provide the most A must for the reference library of anyone in the current information and recommendations environmental health profession, this book focuses for communicable-disease prevention. The on factors that are generally associated with the CCDM is designed to be an authoritative outdoor environment. It was written by experts in reference for public health workers in the field and copublished with the National official and voluntary health agencies. The Environmental Health Association. A variety of 20th edition sticks to the tried and tested environmental issues are covered such as toxic air structure of previous editions. Chapters pollutants and air quality control; risk assessment; have been updated by international experts. solid and hazardous waste problems and controls; safe drinking New disease variants have been included and some chapters have water problems and standards; onsite and public sewage problems been fundamentally reworked. This edition is an update to a and control; plumbing hazards; air, water, and solid waste milestone reference work that ensures the relevance and programs; technology transfer; GIS and mapping; bioterrorism and usefulness to every public health professional around the world. security; disaster emergency health programs; ocean dumping; and The CCDM is a study reference for NEHA’s Registered much more. Study reference for NEHA’s Registered Environmental Environmental Health Specialist/Registered Sanitarian and Health Specialist/Registered Sanitarian credential exam. Certified Professional–Food Safety credential exams. 876 pages / Hardback 729 pages / Paperback Volume 2: Member: $195 / Nonmember: $215 Member: $59 / Nonmember: $64 Two-Volume Set: Member: $349 / Nonmember: $379

40 Volume 81 • Number 4

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November 2018 • Journal of Environmental Health 41

JEH11.18_PRINT.indd 41 10/4/18 3:10 PM updated

YOUR ASSOCIATION NEHA ORGANIZATIONAL MEMBERS

Sustaining Members EcoSure MFC Center for Health Steritech Group, Inc. [email protected] [email protected] www.steritech.com Accela www.accela.com Erie County Department of Health Multnomah County Environmental Sweeps Software, Inc. www.erie.gov/health Health www.sweepssoftware.com Advanced Fresh Concepts Corp. https://multco.us/health www.afcsushi.com Georgia Department of Public Health, Taylor Technologies, Inc. Environmental Health Section Nashua Department of Health www.taylortechnologies.com Allegheny County Health Department http://dph.georgia.gov/ http://nashuanh.gov/497/ Texas Roadhouse www.achd.net environmental-health Public-Health-Community-Services www.texasroadhouse.com American Chemistry Council Giant Eagle, Inc. National Environmental Health Science Thurston County Public Health www.americanchemistry.com www.gianteagle.com & Protection Accreditation Council and Social Services Department www.nehspac.org Arlington County Public Health Gila River Indian Community: www.co.thurston.wa.us/health Division Environmental Health Service New Mexico Environment Department www.arlingtonva.us Tri-County Health Department www.gilariver.org www.env.nm.gov www.tchd.org Association of Environmental Health GOJO Industries, Inc. New York City Department Academic Programs Tyler Technologies www.gojo.com/foodservice of Health and Mental Hygiene www.aehap.org www1.nyc.gov/site/doh/index.page www.tylertech.com Green Home Solutions Baltimore City Health Department, Washington County Environmental www.greenhomesolutions.com North Bay Parry Sound District Office of Chronic Disease Prevention Health Unit Health (Oregon) https://health.baltimorecity.gov/ Health Department of Northwest www.myhealthunit.ca/en/index.asp www.co.washington.or.us/hhs/ programs/health-resources-topic Michigan environmentalhealth www.nwhealth.org Nova Scotia Environment Bureau of Community and Children’s https://novascotia.ca/nse Waukesha County Environmental Environmental Health, Lead Program HealthSpace USA Inc Health Division www.houstontx.gov/health/Environmental/ www.healthspace.com NSF International www.waukeshacounty.gov/ehcontact www.nsf.org community_childrens.html Hedgerow Software US, Inc. Wegmans Food Markets, Inc. CDC ATSDR/DCHI www.hedgerowsoftware.com Oklahoma Department of www.wegmans.com www.atsdr.cdc.gov/hac Environmental Quality Heuresis Corporation www.deq.state.ok.us Yakima Health District Chemstar Corporation www.heuresistech.com www.yakimacounty.us/275/ www.chemstarcorp.com Oneida Indian Tribe of Wisconsin Health-District IAPMO R&T https://oneida-nsn.gov/resources/ Chester County Health Department www.iapmort.org environmental www.chesco.org/health Educational Members Industrial Test Systems, Inc. Opportunity Council/Building Colorado State University City of Independence www.sensafe.com Performance Center http://csu-cvmbs.colostate.edu/ www.ci.independence.mo.us www.buildingperformancecenter.org Jackson County Environmental Health academics/erhs City of Racine Public Health Department www.jacksongov.org/442/ Orkin Commercial Services Eastern Kentucky University http://cityofracine.org/Health Environmental-Health-Division www.orkincommercial.com http://ehs.eku.edu City of St. Louis Department of Health Jefferson County Public Health Otter Tail County Public Health The University of Findlay www.stlouis.mo.gov/government/ (Colorado) www.co.ottertail.mn.us/494/Public-Health www.findlay.edu departments/health http://jeffco.us/public-health Ozark River Portable Sinks University of Illinois Coconino County Public Health Kanawha-Charleston Health www.ozarkriver.com Department of Public Health www.coconino.az.gov/221/Health Department Paper Thermometer Co. www.uis.edu/publichealth http://kchdwv.org Colorado Department of Public www.paperthermometer.com University of Illinois, Health and Environment, Division Kentucky Department of Public Health Polk County Public Works Illinois State Water Survey of Environmental Health and http://chfs.ky.gov/agencies/dph/Pages/ www.polkcountyiowa.gov/publicworks www.isws.illinois.edu Sustainability, DPU default.aspx www.colorado.gov/pacific/cdphe/dehs Procter & Gamble Co. University of Illinois Springfield LaMotte Company www.pg.com www.uis.edu/publichealth Custom Data Processing, Inc. www.lamotte.com www.cdpehs.com Protec Instrument Corporation University of Wisconsin–Madison, Lenawee County Health Department www.protecinstrument.com University Health Services Diversey, Inc. www.lenaweehealthdepartment.org www.diversey.com SAI Global, Inc. www.uhs.wisc.edu Louisiana State Board of Examiners www.saiglobal.com University of Wisconsin–Stout, DuPage County Health Department for Sanitarians College of Science, Technology, www.dupagehealth.org www.lsbes.org Salcor, Inc. [email protected] Engineering, and Mathematics Eastern Idaho Public Health Maricopa County www.uwstout.edu Department Environmental Services Seattle & King County Public Health Western Carolina University, www.phd7.idaho.gov www.maricopa.gov/631/ www.kingcounty.gov/depts/health.aspx School of Health Sciences Ecobond LBP, LLC Environmental-Services Starbucks Coffee Company www.wcu.edu www.ecobondlbp.com Metro Public Health Department www.starbucks.com Ecolab www.nashville.gov/Health-Department. Stater Brothers Market www.ecolab.com aspx www.staterbros.com

42 Volume 81 • Number 4

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Walter S. Mangold Award 2019The Walter S. Mangold Award recognizes an individual The Mangold is NEHA’s most prestigious award for extraordinary achievement in environmental and while it recognizes an individual, it also honors health. Since 1956, this award acknowledges the an entire profession for its skill, knowledge, and brightest and best in the profession. NEHA is commitment to public health. currently accepting nominations for this award by an aliate in good standing or by any ﬁve NEHA Nomination deadline is members, regardless of their aliation. March 15, 2019.

For application instructions, visit www.neha.org/about-neha/awards/walter-s-mangold-award.

2019 Joe Beck Educational Contribution Award This award was established to recognize NEHA members, teams, or organizations for an outstanding educational contribution within the ﬁeld of environmental health. Named in honor of the late Professor Joe Beck, this award provides a pathway for the sharing of creative methods and tools to educate one another and the public about environmental health principles and practices. Don’t miss this opportunity to submit a nomination to highlight the great work of your colleagues!

Nomination deadline is March 15, 2019.

To access the online application, visit www.neha.org/about-neha/awards/joe-beck-educational-contribution-award.

November 2018 • Journal of Environmental Health 43

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Affiliate Presidents Kentucky—Jessica Davenport, The board of directors includes NEHA’s nationally Kentucky Dept. of Public Health. Alabama—Melanie Boggan, REHS, [email protected] elected officers and regional vice-presidents. Affiliate Assistant Environmental Health Director, Massachusetts—Robin Williams, presidents (or appointed representatives) comprise Alabama Dept. of Public Health. [email protected] REHS/RS, Framingham Dept. of Public the Affiliate Presidents Council. Technical advisors, Health, Marlborough, MA. Alaska—Shelley A. Griffith, DrPH, [email protected] the executive director, and all past presidents of the Environmental Health Program Manager, Municipality of Anchorage, AK. Michigan—Brian Cecil, BTC Consulting. association are ex-officio council members. This list Roy Kroeger, REHS [email protected] Second Vice-President shelley.griffi[email protected] is current as of press time. Minnesota—Caleb Johnson, Planner Arizona—Steve Wille, Maricopa Principal, Minnesota Dept. of Health, St. County Environmental Services Dept., Paul, MN. Phoenix, AZ. [email protected] National Officers Colorado, Montana, Utah, Wyoming, [email protected] and members residing outside of the U.S. Missouri—Brian Keller. President—Vince Radke, MPH, RS, (except members of the U.S. armed forces). Arkansas—Richard Taffner, RS. [email protected] CP-FS, DLAAS, CPH, Environmental Term expires 2021 [email protected] Health Specialist, Atlanta, GA. Region 4—Kim Carlton, MPH, REHS/RS, Montana—Alisha Johnson, Missoula [email protected] Business and Industry—Traci Environmental Health Supervisor, Minnesota City County Health Dept., Missoula, MT. Slowinski, REHS, CP-FS, Dallas, TX. Department of Health, St. Paul, MN. [email protected] President-Elect—Priscilla Oliver, PhD, [email protected] Life Scientist, Atlanta, GA. [email protected] Iowa, Minnesota, Nebraska, North Dakota, National Capital Area—Kristen Pybus, [email protected] California—Jahniah McGill, Vallejo, CA. South Dakota, and Wisconsin. MPA, REHS/RS, CP-FS, Fairfax County [email protected] First Vice-President—Sandra Term expires 2019. Health Dept., VA. Long, REHS, RS, Inspection Services [email protected] Supervisor, City of Plano Health Region 5—Tom Vyles, REHS/RS, CP-FS, Colorado—Ben Metcalf, Tri-County Department, Plano, TX. Environmental Health Manager, Town of Health Department, Greenwood Nebraska—Harry Heafer, REHS, [email protected] Flower Mound, TX. Village, CO. Environmental Health Specialist II, [email protected] [email protected] Lincoln-Lancaster County Health Dept., Second Vice-President—Roy Kroeger, Arkansas, Kansas, Louisiana, Missouri, Lincoln, NE. REHS, Environmental Health Supervisor, New Mexico, Oklahoma, and Texas. Term Connecticut—Phyllis Amodio, MPH, RS, [email protected] Cheyenne/Laramie County Health expires 2020. REHS, Chief Sanitarian, Bristol Burlington Department, Cheyenne, WY. Health District, Bristol, CT. Nevada—Erin Cavin, REHS, Region 6—Lynne Madison, RS, [email protected] [email protected] Environmental Health Specialist II, Environmental Health Division Director, Southern Nevada Health District, Immediate Past-President—Adam Western UP Health Department, Florida—Latoya Backus, Largo, FL Las Vegas, N V. London, RS, MPA, Health Officer, Hancock, MI. [email protected] [email protected] Kent County Health Department, [email protected] Grand Rapids, MI. Illinois, Indiana, Kentucky, Michigan, Georgia—Jessica Badour. [email protected] New Jersey—Paschal Nwako, MPH, and Ohio. Term expires 2019. [email protected] PhD, REHS, CHES, DAAS, Health NEHA Executive Director—David Region 7—Tim Hatch, MPA, REHS, Deputy Officer, Camden County Health Dept., Idaho—Sherise Jurries, Environmental Dyjack, DrPH, CIH, (nonvoting Director and Director of Logistics and Blackwood, NJ. Health Specialist Sr., Public Health–Idaho ex-officio member of the board of Environmental Programs, Alabama [email protected] North Central District, Lewiston, ID. directors), Denver, CO. Department of Public Health, Center for [email protected] [email protected] Emergency Preparedness, Montgomery, AL. New Mexico—Cecelia Garcia, MS, [email protected] CP-FS, Environmental Health Specialist, Illinois—David Banaszynski, Alabama, Florida, Georgia, Mississippi, North City of Albuquerque Environmental Regional Vice-Presidents Environmental Health Officer, Carolina, South Carolina, and Tennessee. Health Dept., Albuquerque, NM. Hoffman Estates, IL. Term expires 2020. [email protected] Region 1—Matthew Reighter, MPH, [email protected] REHS, CP-FS, Retail Quality Assurance North Carolina–Daniel Ortiz, Manager, Starbucks Coffee Company, Region 8—LCDR James Speckhart, MS, Indiana—Jason Ravenscroft, MPH, Cumberland County Public Health, Seattle, WA. USPHS, Health and Safety Officer, FDA, REHS, Marion County Health Dept., Autryville, NC. [email protected] CDRH-Health and Safety Office, Silver Spring, MD. Indianapolis, IN. [email protected] Alaska, Idaho, Oregon, and Washington. [email protected] Term expires 2020. [email protected] Delaware, Maryland, Pennsylvania, Virginia, North Dakota—Grant Larson, Fargo Region 2—Major Jacqueline Reszetar, MS, Washington, DC, West Virginia, and Iowa—Don Simmons, State Hygienic Cass Public Health, Fargo, ND. REHS, U.S. Army, Retired, Henderson, N V. members of the U.S. armed forces residing Lab, Ankeny, IA. [email protected] [email protected] outside of the U.S. Term expires 2021. [email protected] Arizona, California, Hawaii, and Nevada. Northern New England Environmental Term expires 2021. Region 9—Larry Ramdin, REHS, CP-FS, Jamaica—Rowan Stephens, Health Association—Brian Lockard, HHS, Health Agent, Salem Board of Health, St. Catherine, Jamaica. Health Officer, Town of Salem Health Region 3: Rachelle Blackham, MPH, Salem, MA. [email protected] Dept., Salem, NH. LEHS, Environmental Health Deputy [email protected] [email protected] Director, Davis County Health Department, Connecticut, Maine, Massachusetts, New Kansas—Shawn Esterl, Saline County Clearfield, UT. Hampshire, New Jersey, New York, Rhode Environmental Services, Salina, KS. Ohio—Garrett Guillozet, MPA, RS/ [email protected] Island, and Vermont. Term expires 2019. [email protected] REHS, Franklin County Public Health,

44 Volume 81 • Number 4

JEH11.18_PRINT.indd 44 10/4/18 3:10 PM YOUR ASSOCIATION

Columbus, OH Cannabis—Cindy Rice, MSPH, RS, Injury Prevention—Alan Trisha Bramwell, Sales and Training [email protected] CP-FS, CEHT, Eastern Food Safety. Dellapenna, RS, North Carolina Support, NEHA EZ, ext. 340, [email protected] Division of Public Health. [email protected] Oregon—William Emminger, REHS/RS, [email protected] Kaylan Celestin, Public Health Corvallis, OR. Children’s Environmental Health— Associate, ext. 320, [email protected] [email protected] Cynthia McOliver, MPH, PhD, U.S EPA. Institutions—Robert W. Powitz, [email protected] MPH, PhD, RS, CP-FS, R.W. Kristie Denbrock, Chief Learning Past Presidents—David E. Riggs, MS, Powitz & Associates, PC. Officer, ext. 313, [email protected] Climate Change—Richard Valentine, [email protected] REHS/RS, Longview, WA. David Dyjack, Executive Director, ext. 301, [email protected] Salt Lake County Health Dept. [email protected] Land Use Planning and Design/ [email protected] Built Environment—Kari Rhode Island—Dottie LeBeau, CP-FS, Santiago Ezcurra, Media Production Drinking Water—Craig Gilbertson, Sasportas, MPA, PhD, Cambridge Food Safety Consultant and Educator, Specialist, NEHA EZ, ext. 342, Minnesota Dept. of Health. Public Health Dept. Dottie LeBeau Group, Hope, RI. [email protected] [email protected] [email protected] [email protected] Soni Fink, Strategic Sales Coordinator, Emergency Preparedness and Land Use Planning and Design/ ext. 314, [email protected] South Carolina—Melissa Tyler, Built Environments—Robert Response—Marcy Barnett, MA, Nancy Finney, Technical Editor, NEHA Environmental Health Manager II, Washam, MPH, RS. MS, REHS, California Dept. EZ, ext. 326, [email protected] SCDHEC, Cope, SC. of Public Health, Center for [email protected] [email protected] Sarah Hoover, Credentialing Manager, Environmental Health. Leadership—Robert Custard, ext. 328, [email protected] [email protected] REHS, CP-FS, Environmental Tennessee—Eric L. Coffey, Health Leadership Partners, LLC. Arwa Hurley, Website and Digital Media Chattanooga, TN. Emergency Preparedness and [email protected] Specialist, ext. 327, [email protected] [email protected] Response—Martin A. Kalis, CDC. [email protected] Onsite Wastewater—Sara Elizabeth Landeen, Associate Director, Texas—Russell O’Brien, RS. Simmonds, MPA, REHS, Kent Program and Partnership Development [email protected] Emerging General Environmental County Health Dept. (PPD), (702) 802-3924, [email protected] Health—Tara Gurge, Needham [email protected] Angelica Ledezma, AEC Manager, Health Dept. Uniformed Services—MAJ Sean ext. 302, [email protected] Beeman, MPH, REHS, CPH, [email protected] Premise Plumbing—Andrew Colorado Springs, CO. Pappas, MPH, Indiana State Dept. Matt Lieber, Database Administrator, [email protected] Food (including Safety and of Health. ext. 325, mlieber@ne ha.org Defense)—Eric Bradley, MPH, [email protected] Bobby Medina, Credentialing Dept. Utah—Sam Marsden, Utah County REHS, CP-FS, DAAS, Scott Uniformed Services—Welford Customer Service Coordinator, ext. 310, Health Dept., West Valley City, UT. County Health Dept. Roberts, MS, PhD, RS, REHS, [email protected] [email protected] [email protected] DAAS, Edaptive Computing, Inc. Marissa Mills, Human Resources Food (including Safety and [email protected] Manager, ext. 304, [email protected] Virginia—David Fridley, Environmental Defense)—John Marcello, CP-FS, Health Supervisor, Virginia Dept. of Eileen Neison, Credentialing Specialist, REHS, FDA. Vector Control/Zoonotic Diseases— Health, Lancaster, VA. ext. 339, [email protected] [email protected] Mark Beavers, MS, PhD, [email protected] Rollins, Inc. Carol Newlin, Credentialing Specialist, Food and Emergencies—Michele [email protected] ext. 337, [email protected] Washington—Mike Young, Snohomish DiMaggio, REHS, Contra Costa Vector Control/Zoonotic Diseases— Christine Ortiz Gumina, Project Health District, Everett, WA. Environmental Health. Christine Vanover, MPH, REHS, CDC Coordinator, PPD, [email protected] [email protected] [email protected] NCEH/ATSDR. Barry Porter, Financial Coordinator, [email protected] West Virginia—David Whittaker. General Environmental Health— ext. 308, [email protected] [email protected] Timothy Murphy, PhD, REHS/RS, Vector Control/Zoonotic Diseases— Kristen Ruby-Cisneros, Managing DAAS, The University of Findlay. Tyler Zerwekh, MPH, DrPH, REHS, Wisconsin—Sonja Dimitrijevic, Dept. Editor, Journal of Environmental Health, murphy@ﬁndlay.edu Shelby County Health Dept. of Agriculture, Trade, and Consumer ext. 341, [email protected] [email protected] Protection, WI. Global Environmental Health— Allison Schneider, CDC Public Health [email protected]. Crispin Pierce, PhD, University of Water Quality—Maureen Pepper, Associate, PPD, ext. 307, Wisconsin–Eau Claire. Idaho Dept. of Environmental Quality. [email protected] Wyoming—Todd Denny, Basin, WY. [email protected] [email protected] [email protected] Robert Stefanski, Marketing and Global Environmental Health— Women’s Issues—Michéle Samarya- Communications Manager, ext. 344, Sylvanus Thompson, PhD, Timm, MA, HO, MCHES, REHS, [email protected] Technical Advisors CPHI(C), Toronto Public Health. DLAAS, Somerset County Dept. of Health. Reem Tariq, Project Coordinator, PPD, [email protected] [email protected] ext. 319, [email protected] Air Quality—David Gilkey, PhD, Montana Tech University. Government Representative— Christl Tate, Program Manager, PPD, [email protected] Timothy Callahan, Georgia Dept. NEHA Staff: ext. 305, [email protected] (303) 756-9090 of Public Health. Sharon Unkart, Instructional Designer, Aquatic Health/Recreational Health— [email protected] NEHA EZ, ext. 317, [email protected] Tracynda Davis, MPH, Davis Strategic Seth Arends, Graphic Designer, NEHA Consulting, LLC. Industry—Nicole Grisham, Entrepreneurial Zone (EZ), ext. 318, Gail Vail, Director, Finance, ext. 309, [email protected] University of Colorado. [email protected] [email protected] [email protected] Jonna Ashley, Association Membership Sandra Whitehead, Director, PPD, Aquatic Health/Recreational Health— Manager, ext. 336, [email protected] [email protected] CDR Jasen Kunz, MPH, REHS, USPHS, Information and Technology— CDC/NCEH. Darryl Booth, MPA, Accela. Rance Baker, Director, NEHA EZ, ext. Joanne Zurcher, Director, Government [email protected] [email protected] 306, [email protected] Affairs, [email protected]

November 2018 • Journal of Environmental Health 45

JEH11.18_PRINT.indd 45 10/4/18 3:10 PM A Tribute to Our 25–YEAR MEMBERS e would like to thank and honor the individuals listed below who have been members of the National Environmental Health Association for 25 years or longer. We sincerely appreciate their commitment to W our association and the environmental health profession.

A Anthony E. Bennett C Richard F. Collins Accela Steve L. Berry Gregory Cabose Kenneth L. Conright Adesegun A. Adefuye Jerene Beyer Dennis P. Campbell Keith W. Cook Karen L. Ahrendt Chirag H. Bhatt Elizabeth A. Campbell Jeffrey R. Coombs Anthony C. Aiken Robert Bialas Robert J. Canning Ralls M. Coston

Tunde M. Akinmoladun David B. Cramer Michael E. Bish Thomas G. Carbone Thomas J. Anderson Alan M. Croft Stephen R. Blackwell Carl I. Carroll Peter R. Andrews Catherine W. Cummins Robert Blake Karen A. Casale Bennett H. Armstrong Joseph F. Curlee Glenn R. Blanchette James L. Casaus Thomas W. Ashton Charles Catlin Robert W. Custard Arthur W. Bloom Steven K. Ault Robin L. Chapell Dean Bodager D Penny J. Chencharick B James H. Bowles Richard A. Daugherty Dale A. Baker Jeffrey A. Church David C. Breeding Trenton G. Davis Gary Baker Kenneth A. Clare Kevin P. Breen Melburn R. Dayton

James J. Balsamo Nancy M. Clark Daniel De La Rosa Robert E. Brewster Darryl B. Barnett Richard W. Clark Cynthia P. DeCristofaro Edward L. Briggs John M. Barry Lynne W. Clem Edward A. Deep Corwin D. Brown Dale M. Bates Gordon Clemans Joseph Del Ferro Jeffrey L. Buntrock Davies H. Batterton Gary E. Coleman Alan J. Dellapenna Thomas J. Butts Renee L. Beckham Holly H. Coleman Dan T. Dennison

Delbert T. Bell Brian K. Collins James E. Devore

46 Volume 81 • Number 4

JEH11.18_PRINT.indd 46 10/4/18 3:10 PM James D. Dingman LuAnn M. Ford William H. Hayes K Michael J. Diskin Morris V. Forsting Gregory M. Heck Richard Kebabjian

Elise A. Dixon Thomas M. Frank Cory D. Hedman Frank E. Kellogg

Bernard A. Dreher David P. Franken Charles H. Henry Dennis B. Kilian

Lisa A. Duello Peggy D. French Donna K. Heran Kelly B. Kirkpatrick-Stock- burger Jozaier T. DuGlas Dixie Fullerton Robert E. Herr David A. Knauf Thomas S. Dunlop Michael E. Herring G Paul L. Knechtges Donna R. Dunn Peter W. Hibbard Frank A. Gabrian Mel Knight James A. Dunning Gary M. Hickman Jeanne M. Galloway Karin Knopp Charles L. Higgins E Eugene K. Garland Diane Knowles Dwight C. Hill Diane R. Eastman Matthew P. Geisert Robert B. Knowles Thomas A. Hill Douglas J. Ebelherr Bruce George Theodore J. Koenig Scott Hipple Christopher Eddy Ginger L. Gist Peter J. Kolodziej John E. Hiramoto Jean V. Edsall Raymond E. Glos Herman Koren James A. Holley Fred Einerman Scott R. Golberg Debra J. Kovacs Scott E. Holmes Amer El-Ahraf Brian Grady Gabriel L. Kowatch Joseph L. Hughart Terry L. Elichuk Carolyn J. Gray Melvin N. Kramer David T. Hunter Terry D. Ellis Harry E. Grenawitzke Larry E. Krebsbach Leslie J. Hutchinson Brian P. Emanuel Ron L. Grimes Keith L. Krinn Robert J. Emery I Roy Kroeger H William B. Emminger Nancy E. Ice Michael G. Halko Michael Kucab Christopher C. Etcheson Michael W. Israel Mary Jacque Hall Cynthia C. Kunkel Bruce M. Etchison George A. Kupfer John M. Halliwill J Diane L. Evans Marlena M. Hamann Olivia Jacobs L Mark A. Hansell Charlotte R. Johnson F James P. LaFleur Wendy L. Fanaselle F. Charles Hart Keith M. Johnson LaMotte Company Donald T. Fanning Mark A. Harvley Bruce A. Jones Jonathan Langer Saba F. Fattaleh Jack B. Hatlen Lisa M. Jones Jim Langevin

Frank S. Ferro Cathy S. Hayden Lynn P. Jones continued on page 48

November 2018 • Journal of Environmental Health 47

JEH11.18_PRINT.indd 47 10/4/18 3:10 PM A Tribute to Our 25–YEAR MEMBERS

continued from page 47 John A. Marcello Monroe T. Morgan P

Roland E. Langford Boyd T. Marsh John E. Morrell Bette J. Packer

Oren L. Larson Joel S. Martens George A. Morris Richard A. Pantages

John P. Leffel Eric D. Martin Milton A. Morris Joseph M. Parker

Mike A. Lester Anthony J. Matarazzo Christine Moser-Fink Clark A. Pearson

Michael A. Letry Mark Mathre Robert Mumper Rick Petersen

Stephanie J. Levell Joseph W. Matthews Brian Murphy Colleen F. Petullo

Allan R. Levesque Ralph M. Matthews Bruce Murphy James M. Phillips

Glenda R. Lewis James P. McCalister Timothy J. Murphy James E. Pierce

Richard L. Licari Harold C. McDowell Michael R. Plemons

Allen R. McKay N Chuck J. Lichon Robert W. Powitz Quanah Nail Scott A. McKenzie Tim A. Link Elizabeth A. Pozzebon George M. Nakamura David H. McMahon Patricia A. Livingston Lewis J. Pozzebon John M. Nason Barry L. McNulty Percell Locklear Michael K. Pyle Robert R. Nelson David Z. McSwane Gus T. Lopez Cecil Newell Q Christopher T. Melchert Thomas I. Lovey Marlene H. Quibell Bart Nighswonger Raymond P. Merry Mina Lovrich-Kerr Gary P. Noonan Jerrold M. Michael R Ross D. Lytle Norman R. Norvelle William R. Milardo Laura A. Rabb

M John M. Milgrim NSF International Vincent J. Radke

Scott L. Maass Deborah A. Miller Naphtali O. Nyagwachi Michael R. Ramdhan

Arthur N. Mabbett Robert Miller Edward H. Rau O Amy A. MacKenzie-Sanders Tomeji Miller Jackie L. Rayburn Mary B. O’Connor Gloria T. Mackie Peter M. Mirandi Karen E. Reid Priscilla Oliver Kathleen MacVarish Lloyd W. Mitchell Roger T. Reid MaryAnn Orapello Kathleen A. Mallet Richard W. Mitzelfelt Michael L. Reiss Ronald J. Osterholm Patrick J. Maloney Nicholas G. Molchan Scott M. Reynolds Charles S. Otto Kenneth Malveaux Robert E. Moore Leonard F. Rice

Richard D. Manney Wendell A. Moore Irene L. Richardson

48 Volume 81 • Number 4

JEH11.18_PRINT.indd 48 10/4/18 3:10 PM Dan Richen Frank S. Sedzielarz Charlene A. Weiss to Our 25–YEAR MEMBERS T David E. Riggs Carrie A. Senseman Stephen R. Tackitt Norman L. Weiss

Janet E. Rittenhouse Ginger L. Shaffer Ryan Talken Michael M. Welch

Richard L. Roberts Charles Shepherd David C. Taylor Susan L. Welch

Welford C. Roberts Craig A. Shepherd Kelly M. Taylor Roxane R. Weldon

Perry L. Robinson Richard A. Sherman Taylor Technologies Inc Daniel M. Wellington

Adam R. Rocke John H. Shrader David W. Tharp April L. Wendling

David J. Rogers David P. Shuemaker Dennis Thayer James M. White

Eldon C. Romney Zia Siddiqi Peter D. Thornton Chris J. Wiant

Deborah M. Rosati Donnie Simmons Richard J. Thoune Donald B. Williams

Richard K. Rowe Bryan T. Slade John G. Todd James S. Williamson

R.J. Rucker Doug R. Smith Donald T. Torres Keith M. Willingham

M.A. Rusiecki Jeffrey J. Smith Michael S. Treppel Edward F. Wirtanen

Thomas L. Russell Sharon L. Smith Charles D. Treser Robert Wolfe

Marcia G. Snyder Brian Turner S Y Stanley J. Sosnicki Douglas E. Turner Dennis A. Salmen Melinda A. Young Vincent A. Spencer James A. Twigg Richard Sanchez Webster Young Philip D. St. Onge Vickie M. Sandoval V Peggy E. Starczowski Z Peter H. Sansone Robert Vaccarella Carl W. Stein George Zameska Joseph M. Sarcone Lawrence G. Van Dyck Grace E. Steinke Brian J. Zamora John P. Sarisky Steve Van Stockum Elena K. Stephens Keith V. Zirkle Wade D. Saucier Laura L. Vasile John A. Steward Barbara A. Zirngibl Paul J. Scaglione Leon F. Vinci Steven Stiefel Patrick Zurick Sue Scheurer Janice Viola Jeffrey T. Stout John E. Schillinger Alex H. Stubner W Vickie Schleuning Laura Studevant Jerry D. Walker Peter M. Schmitt Sandra M. Supinski Michael G. Wallingford Jacqueline L. Schnider Neil R. Swanson Richard M. Walton Ellen M. Schroth Gilbert M. Swe Steven J. Ward Lucy S. Schrum Robert B. Washam

November 2018 • Journal of Environmental Health 49

JEH11.18_PRINT.indd 49 10/4/18 3:10 PM YOUR ASSOCIATION

Statement of Ownership, Management, and Circulation (All Periodicals Publications Except Requester Publications) 1. Publication Title 2. Publication Number 3. Filing Date

_ Journal of Environmental Health 2 7 9 9 0 0 9/27/2018 U.S. Postal 4. Issue Frequency 5. Number of Issues Published Annually 6. Annual Subscription Price Once per month except for two bimonthly issues (January/February and July/August) 10 issues $160.00 7. Complete Mailing Address of Known Office of Publication (Not printer) (Street, city, county, state, and ZIP+4®) Contact Person Kristen Ruby-Cisneros Telephone (Include area code) 720 S. Colorado Blvd., Ste. 1000-N, Denver, CO 80246-1926 303.756.9090, ext. 341 8. Complete Mailing Address of Headquarters or General Business Office of Publisher (Not printer) National Environmental Health Association 720 S. Colorado Blvd., Ste. 1000-N, Denver, CO 80246-1926 9. Full Names and Complete Mailing Addresses of Publisher, Editor, and Managing Editor (Do not leave blank) Service Publisher (Name and complete mailing address) National Environmental Health Association 720 S. Colorado Blvd., Ste. 1000-N, Denver, CO 80246-1926 Editor (Name and complete mailing address) Kristen Ruby-Cisneros, National Environmental Health Association 720 S. Colorado Blvd., Ste. 1000-N, Denver, CO 80246-1926 Managing Editor (Name and complete mailing address) Kristen Ruby-Cisneros, National Environmental Health Association 720 S. Colorado Blvd., Ste. 1000-N, Denver, CO 80246-1926

10. Owner (Do not leave blank. If the publication is owned by a corporation, give the name and address of the corporation immediately followed by the Statement names and addresses of all stockholders owning or holding 1 percent or more of the total amount of stock. If not owned by a corporation, give the names and addresses of the individual owners. If owned by a partnership or other unincorporated firm, give its name and address as well as those of each individual owner. If the publication is published by a nonprofit organization, give its name and address.) Full Name Complete Mailing Address of Ownership National Environmental Health Association 720 S. Colorado Blvd., Ste. 1000-N, Denver, CO 80246-1926 11. Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1 Percent or More of Total Amount of Bonds, Mortgages, or Other Securities. If none, check box None Full Name Complete Mailing Address

12. Tax Status (For completion by nonprofit organizations authorized to mail at nonprofit rates) (Check one) The purpose, function, and nonprofit status of this organization and the exempt status for federal income tax purposes: Has Not Changed During Preceding 12 Months Has Changed During Preceding 12 Months (Publisher must submit explanation of change with this statement)

PS Form 3526, July 2014 [Page 1 of 4 (see instructions page 4)] PSN: 7530-01-000-9931 PRIVACY NOTICE: See our privacy policy on www.usps.com.

13. Publication Title 14. Issue Date for Circulation Data Below Statement of Ownership, Management, and Circulation (All Periodicals Publications Except Requester Publications) 16. Electronic Copy Circulation Journal of Environmental Health September 2018 Average No. Copies No. Copies of Single 15. Extent and Nature of Circulation Average No. Copies No. Copies of Single Each Issue During Issue Published Each Issue During Issue Published Preceding 12 Months Nearest to Filing Date Preceding 12 Months Nearest to Filing Date a. Paid Electronic Copies a. Total Number of Copies (Net press run) 3980 4430 1553 1300 b. Total Paid Print Copies (Line 15c) + Paid Electronic Copies (Line 16a) 5241 (1) Mailed Outside-County Paid Subscriptions Stated on PS Form 3541 (Include paid 5466 distribution above nominal rate, advertiser’s proof copies, and exchange copies) 1261 1036 c. Total Print Distribution (Line 15f) + Paid Electronic Copies (Line 16a) b. Paid 5295 5521 Mailed In-County Paid Subscriptions Stated on PS Form 3541 (Include paid Circulation (2) distribution above nominal rate, advertiser’s proof copies, and exchange copies) (By Mail d. Percent Paid (Both Print & Electronic Copies) (16b divided by 16c Í 100) and 0 0 99% 99% Outside Paid Distribution Outside the Mails Including Sales Through Dealers and Carriers, (3) the Mail) Street Vendors, Counter Sales, and Other Paid Distribution Outside USPS® 0 0 I certify that 50% of all my distributed copies (electronic and print) are paid above a nominal price. Paid Distribution by Other Classes of Mail Through the USPS (4) (e.g., First-Class Mail®) 17. Publication of Statement of Ownership 0 0 c. Total Paid Distribution [Sum of 15b (1), (2), (3), and (4)] If the publication is a general publication, publication of this statement is required. Publication not required. 1261 1036 Will be printed in the November 2018 issue of this publication. d. Free or (1) Free or Nominal Rate Outside-County Copies included on PS Form 3541 Nominal 0 0 18. Signature and Title of Editor, Publisher, Business Manager, or Owner Date Rate Distribution (2) Free or Nominal Rate In-County Copies Included on PS Form 3541 (By Mail 0 0 and Free or Nominal Rate Copies Mailed at Other Classes Through the USPS Outside (3) the Mail) (e.g., First-Class Mail) 0 0 Managing Editor 9/27/2018 I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form (4) Free or Nominal Rate Distribution Outside the Mail (Carriers or other means) 54 55 or who omits material or information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including civil penalties). e. Total Free or Nominal Rate Distribution (Sum of 15d (1), (2), (3) and (4)) 54 55

f. Total Distribution (Sum of 15c and 15e) 1315 1091

g. Copies not Distributed (See Instructions to Publishers #4 (page #3)) 238 209

h. Total (Sum of 15f and g) 1553 1300 i. Percent Paid (15c divided by 15f times 100) 96% 95% * If you are claiming electronic copies, go to line 16 on page 3. If you are not claiming electronic copies, skip to line 17 on page 3.

PS Form 3526, July 2014 (Page 2 of 4) PS Form 3526, July 2014 (Page 3 of 4) PRIVACY NOTICE: See our privacy policy on www.usps.com.

50 Volume 81 • Number 4

JEH11.18_PRINT.indd 50 10/4/18 3:10 PM YOUR ASSOCIATION NEHA NEWS

Call for Nominations tions, and can open doors for NEHA in building relationships with By Angelica Ledezma ([email protected]) industry, academia, federal and state agencies, foundations, and The National Environmental Health Association (NEHA) is gov- other associations. erned by a corporate board of directors who oversee the affairs of Requirements to serve on the board include the association. There will be four board positions up for election • membership with NEHA (individual or life) for three consecu- in 2019: tive years prior to assuming offi ce on July 12, 2019; • Region 4 vice-president (represents Iowa, Minnesota, Nebraska, • not simultaneously holding a voting position on the board of a North Dakota, South Dakota, and Wisconsin; 3-year term); NEHA affi liate; • Region 6 vice-president (represents Illinois, Indiana, Kentucky, • endorsement by at least fi ve voting NEHA members (from mem- Michigan, and Ohio; 3-year term); bers residing in the region for regional vice-president candidates • Region 9 vice-president (represents Connecticut, Maine, Massa- and from members residing in at least three different regions for chusetts, New Hampshire, New Jersey, New York, Rhode Island, second vice-president candidates); and and Vermont; 3-year term); and • willingness to commit the time necessary to actively serve on • second vice-president (national offi cer; 5-year term that pro- the board. gresses through the national offi ces and will serve as NEHA If you are interested in serving on our board of directors, please president in 2022–2023). visit www.neha.org/about-neha/governance/elections for informa- We seek diversity on the board in terms of gender, ethnicity, tion on the nomination and election process. You can also contact and a balance between regulatory offi cials, academia, and indus- NEHA Immediate Past-President Adam London, chairman of NEHA’s t r y. Most importantly, we want people who will help us develop a Nominations Committee, at [email protected]. The new strategic vision, have experience managing diverse organiza- deadline to submit a nomination is December 1, 2018.

ENVIRONMENTAL HEALTH C It’s a tough job. M

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MY Join the only community of people as dedicated

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November 2018 • Journal of Environmental Health 51

JEH11.18_PRINT.indd 51 10/4/18 3:10 PM YOUR ASSOCIATION

DirecTalk Yes, together we have accomplished a lot. continued from page 54 What got us here is us. Every NEHA staff member is an essential contributor to our environmental health network in the Carib- success. I mean that. Our bench is sparse, bean. You will be hearing more about this so in many cases there are no reserves, only project in the future. starters. Many NEHA members have stepped We are also delighted to report that we up to contribute to the association’s success have recently been awarded a 5-year coop- in countless ways over the last year—as com- erative agreement to build the capacity of the mittee members, abstract and article review- national environmental health workforce. The ers, local affi liate leaders, and many other activities under this award will vary from year largely anonymous contributions. In this to year. In the fi rst year, we will receive sup- month of Thanksgiving, whoever you are, I port for climate and health, informatics, and thank you. It’s making a difference. The evi- Health in All Policies, among others. This dence is all around us. grant in many respects places us at the cen- NEHA Government Affairs Director Joanne I close by asking a favor. While we can and ter of the public health conversation, as many Zurcher testifi es in Washington, DC. Photo should enjoy and celebrate the milestones courtesy of Diana Van Vleet. other major associations have been part of this described in this column, now is not the time 83rd ANNUAL EDUCATIONAL funding mechanism for several years. As a side for complacency. Now is not the time for ego. CONFERENCE & EXHIBITION note, we received backhanded praise for our in key federal testimony. We have nominated Now is not the time for crowing. Now is the application. After the award was made, some- individuals for Board of Scientifi c Counselors time to be thankful for each other and to steel Nashville, Tennessee July 9 - July 12 one called me to inquire who we hired to write for CDC’s National Center for Environmen- ourselves for the challenges ahead as they are our grant as it was so well crafted. For the tal Health and National Center for Emerging many and complex. I take solace in know- EXHIBITOR REGISTRATION NOW OPEN! record, we wrote it ourselves, though it was Zoonotic and Infectious Diseases, the U.S. ing it’s you that protects my family when we C burnished by input from some of o ur friends. Environmental Protection Agency, and the eat out, recreate at the beach, or drink water M NEHA.ORGAECEXHIBITION

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Employers increasingly require a professional credential to verify that you are qualiﬁ ed and trained to perform your job duties. Credentials improve the visibility and credibility of our profession and they can result in raises or promotions for the Invest in your growth and your future. holder. For 80 years, NEHA has fostered dedication, Reserve your booth space today! competency, and capability through professional credentialing. We provide a path to those who want neha.org/aec/exhibition to challenge themselves and keep learning every day. Earning a credential is a personal commitment Attendee Registration to excellence and achievement.

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52 Volume 81 • Number 4 NEHA.ORGAEC

JEH11.18_PRINT.indd 52 10/4/18 3:11 PM 83rd ANNUAL EDUCATIONAL CONFERENCE & EXHIBITION Nashville, Tennessee July 9 - July 12 EXHIBITOR REGISTRATION NOW OPEN! C M NEHA.ORGAECEXHIBITION Y

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JEH11.18_PRINT.indd 53 10/4/18 3:11 PM YOUR ASSOCIATION

 DirecTalk MUSINGS FROM THE 10TH FLOOR

Stay Hungry. Stay Foolish.

David Dyjack, DrPH, CIH

book. A slogan. Now it’s the subject Roles in Environmental Health (UNCOVER of an executive director’s column. EH). Focus groups and surveys have been A Stay hungry. Stay foolish. What got us here conducted with representative boots-on-the- We recently convened a 2-day staff retreat ground environmental health profession- to focus on quality improvement and the is us. als to gain perspective into the needs of the road ahead. We jump started the process by profession from the bottom up. This research sharing the 2005 Stanford commencement promises to shine a light on the expressed address given by Apple CEO Steve Jobs in First, let’s examine thought leadership. For needs of you, the individual practitioner. It which he shared his personal insight into many years, federal agencies and other associ- will also describe workforce characteristics, how dropping out of college and being ter- ations were the go-to resource for information who you are, your sex, age, etc. minated from his job led to positive life and about the environmental health profession. Finally, NEHA staff has been working with career transformation. How many environmental health profession- a University of Colorado School of Public The National Environmental Health Asso- als work in the U.S.? What are their profes- Health intern to collect national environ- ciation (NEHA) has varied and profound sional needs? What degrees do they have? mental health service delivery system-level challenges ahead. We need to remain true to How do they receive continuing professional information. How are environmental health the notion that being hungry and foolish are education? How are services delivered? services delivered? Where is the administra- indeed important. During our retreat I added NEHA staff and its partners have three tive home for governmental environmental an additional element to the mix—let’s be peer-reviewed publications planned for the health services in each state and territory? hungry and foolish together. next year intended to answer those ques- How many states are governed by home rule We have been blessed, as an outcome of tions. One of those publications, crafted in and how many are centrally managed? hard work, long hours, and committed staff, partnership with the de Beaumont Founda- While we are working on describing our to have bent the arc of our association and tion and the Association of State and Ter- profession, we have also been burning the the profession toward greatness over the last ritorial Health Offi cials, will share data and midnight oil to ensure we have a sustain- year. Hyperbole, you say. Pride before the insights as an outcome of the Public Health able pool of resources aimed at building fall, you snigger. Let me shine a light on a Workforce Interests and Needs Survey (PH your professional capacity. This endeavor is few examples. Hopefully you’ll have better WINS). This publication will provide a top- most notably evident in providing tools and insight into the spirit of my statements. down perspective, mostly from senior and resources that assist you in advancing your NEHA desires to be an essential partner state level professionals. work. In this case, we have some remarkable and the most infl uential voice in the envi- The second publication, conducted in col- successes to report ronmental health profession. We can achieve laboration with Baylor University, the Cen- NEHA has been entrusted with a multimil- that by being respected thought leaders. We ters for Disease Control and Prevention’s lion-dollar federal award to rebuild environ- can achieve that by providing you with the (CDC) National Center for Environmental mental health in the U.S. Virgin Islands, as tools and resources needed to be effective. We Health, and NEHA staff, will share fi ndings well as smaller and more targeted projects in can achieve that by projecting leadership in from our own efforts. Most of you are familiar Puerto Rico. By the time you read this col- professional circles where decisions are made with this work as many of you participated in umn, the work will be well underway. We feel that affect our profession and the health of this study—Understanding the Needs, Chal- privileged to be part of the solution for the the nation. lenges, Opportunities, Vision, and Emerging continued on page 52

54 Volume 81 • Number 4

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 INTERNATIONAL PERSPECTIVES

Firework-Induced Particulate and Pramod Kumar Heavy Metal Emissions During the University School of Environment Management, Guru Gobind Singh Indraprastha University Diwali Festival in Delhi, India Deen Dayal Upadhyaya College, University of Delhi N.C. Gupta University School of Environment Management, Guru Gobind Singh Indraprastha University

ment as well as human health (Drewnick, Hings, Curtius, Eerdekens, & Williams, Abstract This study deals with the temporal monitoring of air 2006; Dutcher, Perry, Cahill, & Copeland, quality in a densely populated residential area of Delhi to assess the impact 1999; Dwivedi, Tripathi, & Shashi, 2008;

of firework displays on ambient concentrations of PM10, PM2.5, and trace Hirai, Yamazaki, Okada, Furuta, & Kubo, metals in air particulates for pre-Diwali, Diwali, and post-Diwali festival 2000; Kulshrestha, Nageswara Rao, Azhagu- vel, & Kulshrestha, 2004; Liu, Rutherford, times during 2012 and 2013. We monitored for particulate concentration, Kinsey, & Prather, 1997; Mandal, Sen, & which causes adverse health effects, during morning and evening hours. The Sen, 1997; Ravindra, Mor, & Kaushik, 2003; use of fireworks during Diwali increased 1.6–1.9 times in the concentration Tripathi & Gautam, 2007). Concentrations

of PM10 and increased 1.7–2.1 times in the concentration of PM2.5 as com- of these pollutants depend on the composi- pared with pre- and post-Diwali during our monitoring in 2012. In 2013, tion of the fireworks and sparklers (Barman, Singh, Negi, & Bhargava, 2009). however, PM concentration increased 1.5–2.0 times and PM increased 10 2.5 Worldwide, researchers have reported the 1.7–2.2 times. The average concentration of particulates on the day of Di- effect of firework activities on the air qual- wali was higher in 2012 compared with 2013, which might be attributed to ity with particulate matter, its components, adverse meteorological conditions. The following average concentrations (in and often trace gases during various festivals μg/m3) were associated with particulates on Diwali in 2013, in order: alumi- such as the Lantern Festival in China (Wang, Zhuang, Xu, & An, 2007), Independence num (19.47) > magnesium (11.39) > sulfur (7.69) > potassium (6.50) > iron Day in the U.S. (Liu et al., 1997), and New (0.74) > zinc (0.30) > lead (0.13) > copper (0.09). Year’s (Drewnick et al., 2006). In India, a few groups have reported degradation of air quality due to firework activities Introduction degradation significantly affect human health during Diwali festival. Kulshrestha and coau- Air quality of megacities such as Delhi is of and have long-term negative impacts, which thors (2004) reported a high level of different serious concern due to its high pollutant con- are drawing the attention of the scientific trace elements in ambient air of Hyderabad, centrations and resulting serious health haz- community (Nastos, Paliatsos, Anthracopou- India, due to fireworks. Ravindra and coau- ards, making it an important issue to current los, Roma, & Priftis, 2010; Pope et al., 2002; thors (2003) observed an increase of 2–10 environmental researchers (Kumar, Chandra Samoli, Nastos, Paliatsos, Katsouyanni, & times in concentrations of PM10, total sus-

Gupta, & Singh Parmar, 2014; Paschalidou Priftis, 2011). pended particulates, nitrogen dioxide (NO2),

& Kassomenos, 2004). People residing in Diwali is one of the major festivals that is and sulfur dioxide (SO2) in the city of Hisar, urban areas are often exposed to a complex celebrated with great fervor across India in India, during Diwali. Barman and coauthors mixture of environmental pollutants due to the months of October and November. Fire- (2009) noticed a remarkable increase in PM2.5 heterogeneous and spatial distribution of crackers bursting during this festival are an concentration in the city of Lucknow, India. emission sources and prevailing meteorologi- integral part of the festivity. Fireworks are Apart from the joy provided by the splendid cal conditions. Certain predetermined pat- reported to emit trace gases, particulates, and scenes of multicolored lights in the sky and terns associated with the local meteorological metals into the atmosphere, which generate the excitement of resounding firecracker det- conditions of urban air pollution episodes dense clouds of smoke containing potassium onations, the burning of fireworks is a source have also been reported (Singh et al., 2010). nitrate, sulphur, and several other trace ele- of airborne pollutants, including trace metals

Further, episodes of short-term air quality ments, which severely affects the environ- and ozone (O3).

November 2018 • Journal of Environmental Health • Volume 81, Number 4 E1 E-JOURNAL ARTICLE

additional burden on air quality due to the Diwali festival held in Delhi, where air pollu- FIGURE 1 tion is an acute problem throughout the year. Comparison of the Air Quality Index for the Diwali Festival, 2012 and This study aimed to understand the short- 2013, East Delhi, India term changes in air quality during the Diwali festival and its comparison with air quality 1,200 data from previous years. The study provides PM 10 useful information regarding the changes 1,000 5:00–10:30 a.m. that occurred in air quality during 2 consecu- 6:00–11:00 p.m. tive years (2012 and 2013). 800 Materials and Methods 600 Study Site and Sample Collection 400 The national capital territory of Delhi Air Quality Index (28°38’ N and 77°20’ E, 216 m above mean 200 sea level) occupies an area of 1,483 km2 and 0 has a population of nearly 14 million as per Pre-Diwali Diwali Post-Diwali Pre-Diwali Diwali Post-Diwali the Census of India. The Central Pollution 2012 2012 2012 2013 2013 2013 Control Board (CPCB) of India has identified the city of Delhi as one of the most 1,400 polluted urban areas in the country (and in PM 2.5 the world in terms of air pollution). The 1,200 5:00–10:30 a.m. sampling site, East Delhi (28°48.01’ N; 6:00–11:00 p.m. 1,000 77°17.00’ E), is located in the Trans-Yamuna area. In the east, the sampling site is sur- 800 rounded by the border of Uttar Pradesh, comprising the cities of Noida and Gha- 600 ziabad. The sampling site has an elevation

Air Quality Index 400 of 239 m above sea level. East Delhi has a population of 1,448,770 (2001 census) and 200 an area of 64 km², with a high population density of 22,638 persons/km². 0 Pre-Diwali Diwali Post-Diwali Pre-Diwali Diwali Post-Diwali The monitoring station was chosen on 2012 2012 2012 2013 2013 2013 the terrace of a 3-story private building in a densely populated residential area at the outside zone of influence of other sources located within the designated zone for the monitoring. Several studies have reported a firework- The aesthetic of the lighting of firecrackers and The sampling was carried out in accordance related increase in the concentration of surface sparklers, along with the noise, seem essential with CPCB guidelines. The terrace was chosen ozone in Delhi (Attri, Kumar, & Jain, 2001; and appropriate to the Diwali festival. The use for sampling because the nearby houses have Ganguly, 2009). Fireworks emit airborne par- of colored sparklers by children at ground level, roof spaces that are used by residents for the ticles consisting of various elements, including however, can put them at a severe exposure of firework display. No major industrial sources aluminum (Al), barium (Ba), cadmium (Cd), inhaling the resulting pollutants. are located within 5 km around the site. copper (Cu), potassium (K), and manganese The purpose of this study was to compare Sampling of PM10 and PM2.5 was conducted (Mn), as well as other heavy metals that are the concentrations of particulates and met- on the rooftop of the private building (approx- deleterious to human health (Moreno et al., als with other similar studies conducted in imately 12 m above ground level). The sam- 2007; Ravindra et al., 2003; Vecchi et al., 2008). various cities across India around the times pling site of the rooftop was maintained at a Hirai and coauthors (2000) observed that of Diwali. The air quality variations during suitable distance from any other direct pol- inhalation of smoke from fireworks can cause Diwali were monitored for 2 consecutive years lution source, including traffic. The nearby cough, fever, and dyspnea, and lead to acute (2012 and 2013) with a short-term sampling buildings in the sampling zone were of similar eosinophilic pneumonia. Short-term elevated program during Diwali festival (November heights and the sampler was kept away from emissions of trace elements from fireworks can 10–16, 2012, and October 31–November any obstructions to airflow. In addition, this also trigger several health problems in humans 6, 2013) at different residential locations in height can be considered as the respirable such as neurological and hematological effects. Delhi. Overall, we attempted to assess the zone for people in 2- and 3-story buildings.

November 2018 • Journal of Environmental Health • Volume 81, Number 4 E2 E-JOURNAL ARTICLE

TABLE 1 Meteorological Parameters for the Diwali Festival Fireworks Display, 2012 and 2013, Delhi, India

Time Period Date Maximum Minimum Average Average Relative Average Wind Speed Temperature (°C) Temperature (°C) Temperature (°C) Humidity (%) (km/hr) 2012 Pre-Diwali festival 11/10/12 30 16 23 48 5 11/11/12 22 16 19 69 3 11/12/12 28 16 22 64 2 Diwali festival 11/13/12 27 15 21 66 2 Post-Diwali festival 11/14/12 26 13 20 64 3 11/15/12 27 14 20 66 2 11/16/12 26 13 20 64 1 2013 Pre-Diwali festival 10/31/13 30 20 25 55 5 11/1/13 29 19 24 57 6 11/2/13 27 17 22 63 4 Diwali festival 11/3/13 28 14 21 54 6 Post-Diwali festival 11/4/13 28 13 20 57 2 11/5/13 25 13 19 66 7 11/6/13 27 14 20 60 5

Sampling Procedure most variation in air quality in Delhi (Soni et breathing unhealthy air. The concentrations of In order to study the temporal variation in al., 2010). The monitoring duration chosen associated pollutants are monitored and sub- distribution and concentrations of PM10 and for pre- and post-Diwali was maintained on sequently converted to AQI using the formula

PM2.5 in ambient air due to extreme episodes each monitoring day encompassing the peak shown below. Values in the range of 0–50 during Diwali, air monitoring was carried period of firecracker display. advocate clean air; 51–100 imply moderately out using a portable aerosol spectrometer clean air, and the range 100–150 is indicative (GRIMM model 1.108). The lightweight Analysis for Trace Metals of unhealthy air for sensitive groups. An AQI instrument is easy to handle and operates Particulate matter collected on PTFE filters value above 150 is considered to be unhealthy. efficiently with a given time resolution. The was analyzed by energy dispersion X-ray fluo- Higher values (≥500) refer to a hazardous, sig- GRIMM aerosol spectrometer uses the light rescence (ED-XRF), a nondestructive method nificant level of air pollution. AQI is calculated scattering principle to calculate the number for determination of major elements—Al, by the formula: of particles per unit volume of air. The instru- arsenic (As), Ba, bromine (Br), calcium (Ca), ment displays single particle counts with size chromium (Cr), Cu, iron (Fe), K, magnesium Observed mean concentration classifications in real time. The ambient air (Mg), Mn, nickel (Ni), lead (Pb), phosphorus of a pollutant AQI = 100 × to be analyzed is drawn into the unit via an (P), silicon (Si), sodium (Na), strontium (Sr), Standard for the internal volume-controlled pump at a rate of sulfur (S), titanium (Ti), vanadium (V), and respective pollutant 1.2 L/min. After passing through the sample zinc (Zn). This technology is available at the cell and laser diode detector, sample particles Advanced Instrumentation Research facility of The data obtained from ambient air qual- are collected over a 47-mm PTFE filter. Jawaharlal Nehru University in New Delhi. ity monitoring for pre- and post-Diwali at The monitoring work was designed for the study site were converted to AQI and are a total of 7 days spanning from November Air Quality Index shown in Figure 1. It is observed that the 10–16, 2012, and October 31–November 6, The U.S. Environmental Protection Agency monitoring for the study location indicates 2013, and was divided into three segments. (U.S. EPA) introduced the Air Quality Index severely polluted levels during Diwali. The first segment consisted of 3 consecutive (AQI), an index developed for reporting daily days (3 days before and 3 days after Diwali air quality to measure the levels of pollution Results and Discussion to assess the variation in air quality due to caused by major air pollutants. AQI tells how firecrackers during the festival). The moni- clean or unhealthy air is at a particular location Meteorological Parameters toring was done from 5:00–10:30 a.m. and and what associated health effects might be a Particulates (PM10 and PM2.5) were moni- 6:00–11:00 p.m. during pre- and post-Diwali concern, focusing on health effects that might tored during the Diwali festival to study the episodes, as during this period there was the be experienced within a few hours or days after influence of fireworks in the ambient air of

November 2018 • Journal of Environmental Health • Volume 81, Number 4 E3 E-JOURNAL ARTICLE

East Delhi. The meteorological parameters monitored during Diwali for each year are FIGURE 2 given in Table 1. The temperature (°C), relative humidity (%), and wind speed (km/hr) PM10 and PM2.5 Concentrations in the Ambient Air During the Diwali Festival, 2012 and 2013, East Delhi, India indicate only slight changes during the study period, suggesting minimal interference with the weather. It has been reported that local Ambient Concentration of PM10 During Diwali Festival meteorological conditions can significantly influence the concentration of pollutants via dispersion, resulting in a further dilution of emissions from fireworks.

Variations in Air Particulates

The short-term variations in PM10 and PM2.5 concentrations in the ambient air of East Delhi during Diwali in 2012 and 2013 are shown in Figure 2. The average concentra-

tions of PM10 and PM2.5 in 2012, particularly on the day of Diwali, were found to be 480.9 and 412.4 µg/m3 in the morning and 737.4 and 658.1 µg/m3 in the evening, respectively, which is nearly twofold when compared with pre-Diwali days. The average concentrations

of PM10 and PM2.5 during the day of Diwali in 2013 were 504.1 and 241.0 µg/m3 in the morning and 692.6 and 505.2 µg/m3 in the evening, respectively, which is almost double the readings from pre-Diwali days. These results are in consonance with Ravin- dra and coauthors (2003), who reported that fireworks during the festival led to a short-

Ambient Concentration of PM2.5 During Diwali Festival term variation in air quality and a 2–3 times increase in total suspended particulate matter concentration in the city of Hisar, India. This increase in particular matter mass concentration during Diwali can be attributed to both the firecracker emissions and stable atmospheric conditions in winter.

Interestingly, the concentrations of PM10

and PM2.5 in post-Diwali days were found to be higher than those during pre-Diwali days (Table 2). Fireworks during Diwali festival led to a short-term variation of air quality

and a 2–3 times increase in PM10 (Mandal, Prakash, & Bassin, 2012). The behavior can be explained by considering that the bursting of firecrackers increases the level of particulates in the atmosphere and particulates can remain suspended from several hours to several days in the air before they coagulate and settle to the ground. This phenomenon clearly suggests that finer particulates contributed by firecracker burning can remain suspended for long time in the stable atmosphere even after the festival is over

November 2018 • Journal of Environmental Health • Volume 81, Number 4 E4 E-JOURNAL ARTICLE

TABLE 2

Descriptive Statistics of PM10 and PM2.5 in the Ambient Air During the Diwali Festival, 2012 and 2013, East Delhi, India

Time Statistic Pre-Diwali Festival Day of Diwali Festival Post-Diwali Festival 2012 2013 2012 2013 2012 2013 3 PM10 concentration (μg/m ) 5:00–10:30 a.m. Mean ± SD 308 ± 68 252 ± 78 481 ± 101 504 ± 52 368 ± 42 712 ± 103 Maximum 504 417 633 658 510 988 Minimum 232 102 291 428 315 492 Range 272 316 343 230 195 496 6:00–11:00 p.m. Mean ± SD 389 ± 40 476 ± 42 737 ± 143 693 ± 94 485 ± 98 1,087 ± 107 Maximum 490 594 951 899 633 1,352 Minimum 310 406 504 546 337 902 Range 180 188 447 353 296 450 3 PM2.5 concentration (μg/m ) 5:00–10:30 a.m. Mean ± SD 243 ± 42 139 ± 43 412 ± 77 241 ± 40 325 ± 30 487 ± 60 Maximum 409 247 550 325 396 626 Minimum 206 62 270 151 275 369 Range 203 185 280 174 122 257 6:00–11:00 p.m. Mean ± SD 319 ± 33 229 ± 25 658 ± 136 505 ± 105 427 ± 112 766 ± 62 Maximum 405 269 841 687 587 912 Minimum 233 159 429 349 246 609 Range 172 110 412 339 341 303

(Rao et al., 2012). Moreover, in 2013 during Lippman (1998) estimated that with every mostly of fine particles. The PM10 levels 3 the day of Diwali, an increase in wind speed 10 µg/m increase in concentration of PM10, reported by CPCB at the Shahdara location 3 resulted in a dilution of pollutant concentra- total daily mortality increases by approxi- in 2012 and 2013 were 452 and 416 µg/m , tions, whereas the wind speed was less on the mately 1%. Descriptive statistics of PM10 and respectively, on pre-Diwali day and were 928 3 post-Diwali day, so the resulting concentra- PM2.5 in the ambient air of East Delhi dur- and 1,116 µg/m , respectively, on the day of tions were reported as higher. The increased ing Diwali are shown in Table 2. From the Diwali, which is in agreement with the values concentrations of PM10, SO2, and trace metals table it is evident that the concentration of observed during the study. associated with particulate matter have a direct PM10 and PM2.5 at the study area exceeded the relation with adverse human health as well as maximum permissible limit before and after Diurnal Pattern on the environment (Gupta, Kumar, Kumari, & Diwali. During Diwali, a further increase in The diurnal pattern for the levels of PM10 and

Srivastava, 2003; Maynard & Kuempel, 2005; the concentration of these pollutants was PM2.5 reveals significant changes during day Wang, Bi, Sheng, & Fu, 2006). observed. As the majority of the firework dis- and night. The concentrations of pollutants

Generally, higher concentrations of PM10, plays is on the main day of the festival, the during Diwali nights were higher than their

SO2, and oxides of nitrogen (NOx) are respon- maximum levels were observed on the day of respective daytime levels during both of the sible for respiratory diseases and asthma, car- the Diwali festival. monitoring years (Table 2). Singh and coau- diovascular effects, lung cancer, reproductive Percentages for fine and coarse particles thors (2010) reported a similar phenomenon. disorders, as well as neurological and neuro- during Diwali in Delhi were determined for The lowering of the boundary layer towards psychiatric effects (Curtis, Rea, Smith-Willis, two fractions, averaging 0.3–2.5 µm for fine evening could be one possible reason for this Fenyves, & Pan, 2006). Therefore, acute and 3.5–22.5 µm for coarse. The percentage finding, as this thin layer plays a key role in short-term exposure to particulates—espe- contribution of fine particles during pre- the dispersion and dilution of particulates. cially the PM10 and PM2.5 on pre-Diwali, Diwali, Diwali, Diwali, and post-Diwali days clearly Furthermore, daytime and nighttime concen- and post-Diwali days—is a matter of grave suggests that particulates in the size range of trations of particulates on the day of Diwali concern due to the negative influence of par- 0.3–2.5 μm contributed to more than 99% were significantly higher than pre-Diwali ticulates on human health (Bates, 1996; Giri, of air pollutants, indicating the dominance concentrations (Table 2). Murthy, Adhikary, & Khanal, 2006; Nkwocha of fine particles in the ambient air. From the In general, being a public holiday, vehicu- & Egejuru, 2008; Pope et al., 2002; Seaton, results, it can be understood that the emis- lar pollution has been observed to be lower MacNee, Donaldson, & Godden, 1995). sion of particulates from fireworks consists on the day of Diwali compared with a pre-

November 2018 • Journal of Environmental Health • Volume 81, Number 4 E5 E-JOURNAL ARTICLE

FIGURE 3 Comparison of Metal Concentrations During the Diwali Festival, 2012 and 2013, East Delhi, India

25 25 2012 2013 20 20 ) )

3 Pre-Diwali 3 Pre-Diwali m m / Post-Diwali / Diwali g g µ µ ( 15 ( Post-Diwali

15 n n o o i i ra t ra t t 10 t 10 ce n ce n n n o o C 5 C 5

0 0 Mg Al S K Fe Cu Zn Pb Mg Al S K Fe Cu Zn Pb Metal Metal

Note. Data for the metals for Diwali day 2012 are not given as the sample was degraded and could not be analyzed. Mg = magnesium; Al = aluminum; S = sulfur; K = potassium; Fe = iron; Cu = copper; Zn = zinc; Pb = lead.

Diwali day. Also, increase in concentration matter of fine size into the atmosphere, lead- decreases effectively with increasing tem- indicated persistence of these particulates ing to serious health hazards (Do, Wang, perature, wind speed, and relative humidity, in ambient air due to fireworks on the pre- Hsieh, & Hsieh, 2012; Perrino et al., 2011; because pollutants dilute by dispersion when

Diwali night. The concentrations of PM10 Rao et al., 2012). Therefore, particulate wind speed is higher, for example. and PM2.5 have been shown to increase con- samples were further studied for trace met- siderably at night compared with morning, als such as Mg, Al, S, K, Fe, Cu, Zn, and Pb; Conclusion which seems to be associated with increased their presence was found to be higher during This study supports earlier findings that firework events during the night of Diwali Diwali than on normal days (Figure 3). concentrations of particulates increase 2–3 (Table 2). Barman and coauthors (2009), Overall, the concentration of trace met- times on the day of Diwali compared with Thakur and coauthors (2010), and Chatter- als increased due to fireworks on Diwali and pre-Diwali days. Concentrations of all the jee and coauthors (2013) have also observed the percentage increase varied from metal elements of interest were found on the higher similar trends of increase in PM10, PM2.5, to metal (Figure 2). On the day of Diwali, side in the postfirework display period than and other parameters during Diwali due to metal concentration (µg/m3) increased com- the pre-Diwali period during both the years excessive use of firecrackers. The studies pared with a pre-Diwali day (time increase we monitored. The results of PM10, PM2.5, and conducted during Diwali in various parts of shown within parentheses) in 2013: Mg = not trace metals suggest that the use of fireworks India have found an increase in concentra- detected (11.39), Al = 3.89 (15.58), S = 2.78 on pre-Diwali and Diwali nights were found tions of air pollutants during such extreme (4.91), K = 1.1 (5.4), Fe = 0.52 (0.22), Cu = to be responsible for the elevated concentra- events as Diwali (Chatterjee et al., 2013; 0.07 (0.02), Zn = 0.16 (0.14), and Pb = 0.08 tions of these pollutants in ambient air. Nishanth et al., 2012; Perrino et al., 2011; (0.05), and order of concentration was Al > The study indicates that there is a high accu-

Vyas & Saraswat, 2012). Mg > S > K > Fe > Zn > Pb > Cu. mulation of PM2.5 generated due to fireworks Metals such as Mg, Al, S, K, and Zn were during the Diwali festival and that the particu- Metals in Particulate Matter During found in the highest concentration while Pb, late matter remains suspended in the air for a Normal and Festival Days at the East Cu, and Fe were in the lowest concentration. long time. The pre- and post-Diwali days fol- Delhi Site The results obtained indicate that the burning lowed the same trends, but the concentration Materials used in firecrackers contain toxic of fireworks was the main source of elevated was found lowest in pre-Diwali days. A sharp substances and chemicals, the burning of metal concentrations on Diwali night. It is increase in particulate concentration during which releases toxic gases and particulate obvious that the concentration of pollutants the post-Diwali day in 2013 occurred due to

November 2018 • Journal of Environmental Health • Volume 81, Number 4 E6 E-JOURNAL ARTICLE the long atmospheric residence time of par- tion, wind speed, and rain vary widely, so Acknowledgements: The authors are thankful ticulates, which can be attributed to the onset the conditions at the airport were not always to the vice-chancellor of Guru Gobind Singh of winter and stable atmospheric conditions. representative of the study site. Also, the Indraprastha University, Dwarka, New Delhi, AQI for different pollutants was found to data for the metals on Diwali day of 2012 for encouragement and support. The authors be very high, indicating severe pollution due are not given as the sample was degraded would also like to thank Dr. Paramjit Singh to fireworks. The short-term exposure to pol- and could not be analyzed for the metals. for help with preparation of the graphs. lutants above permissible limits can increase The study provides public awareness about the likelihood of acute health effects. Hence, the health risks associated with firework Corresponding Author: N.C. Gupta, Profes- to control the pollution, there is a need for use during Diwali festival and should serve sor, University School of Environment Man- public awareness towards the deleterious as an indicator to take precautions and limit agement, Guru Gobind Singh Indraprastha effects of fireworks. the use of firecrackers during the Diwali University, Room Number AFR-001, Block One of the limitations of the present study festival in a highly populated city such as A, Sector 16C, Dwarka, New Delhi, 110078, was meteorological monitoring. Wind direc- Delhi. India. E-mail: [email protected].

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