Environmental health professionals and emergency preparedness: Canadian perspectives.

Background

Since the terrorist attacks of the fall of 2001, public health agencies have been redefining their roles as first responders. Public health, including environmental health, is part of the overall readiness of all government and private entities. Preparedness has taken center stage at local, state, and federal levels as the nation prepares for future emergencies. Policy makers have tasked public health agencies with developing response plans, training other responders, and responding themselves, all in addition to their standard public health responsibilities. Within the public health field there remains much information to be developed and shared regarding emergency preparedness. Public health officials need to assimilate as much available information as possible and integrate the new data into their preparedness efforts, including information from other nations that have experience of this type.

Identifying the roles and responsibilities of environmental health personnel during a bioterrorism response has not been as straightforward for public health agencies as identifying the roles of other staff. The distinction between the roles of communicable-disease staff and of environmental health officers is sometimes ambiguous. What are the roles of environmental health professionals in terrorism preparedness? As advanced as planning efforts are, there is still uncertainty about where environmental health professionals specifically fit in. Many local and state agencies are looking for emergency response models to assist with the development of their own organization's response plans, especially with definition of the roles of environmental health professionals.

Neither public health nor environmental health is new to emergency preparedness. Many environmental health professionals already respond to natural disasters and chemical spills. For example, environmental health concerns and response efforts at the sites of the September 11, 2001, terrorist attacks addressed air and water quality, radiological and bioterrorism threats, hazardous substances, waste removal, and routine public health checks (sanitation, food handling, restaurant inspections, rodent complaints, and so forth) (Lyman, 2003). The September 11 responses were, however, more ad hoc than a full preparedness plan would allow. Public health agencies need concrete ideas and examples of how to integrate their environmental health employees into their response efforts.

Sabbatical Purpose

The goal of this National Environmental Health Association Canadian Sabbatical, which took place from September 23 to October 17, 2003, was to learn how a local Canadian government agency integrates environmental health professionals into planning, training, and responding to potential public health emergencies. The local Canadian government agency chosen for evaluation was Vancouver's public health system, the Vancouver Coastal Health Authority (VCHA). The objective was to gain an understanding of environmental health professionals' emergency preparedness roles at VCHA. Also, the sabbatical provided an opportunity to collect case studies of environmental health professionals participating in and resolving public and environmental health challenges. Ideas, processes, and strategies used in Vancouver could then be shared with public health colleagues in the United States and potentially applied to their environmental health programs. One agency cannot provide all the information necessary to completely define environmental health roles in emergency preparedness, but it can provide a perspective that, when added to others, can contribute to a better understanding of environmental health roles.

The Vancouver Coastal Health Authority

The Canadian province of British Columbia has five regional health authorities: Vancouver Island Health Authority, Vancouver Coastal Health Authority, Fraser Health Authority, Interior Health Authority, and Northern Health Authority. There is a sixth, centralized health authority, the Provincial Health Authority, which includes the Women's and Children's Hospital, the British Columbia Cancer Agency, and the British Columbia Centre for Disease Control.

VCHA is responsible for planning, funding, coordinating, and providing most public health services in the four health service areas of North Shore/Coast Garibaldi, Vancouver Acute, Vancouver Community, and Richmond. It comprises hospitals, community health clinics, public health, and a recently opened safe-injection site. It serves 25 percent of British Columbia's population, or approximately one million people, and encompasses a geographic area of over 54,000 square kilometers. VCHA has an annual budget of almost two billion Canadian dollars and has 27,000 employees. Over the last 10 years, this regional health authority has developed from what was originally the city of Vancouver's health department. It now oversees almost all public health services in the region.

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Within VCHA is the Office of the Medical Health Officer. This office oversees the public health Offices of Communicable Disease and Health Protection. The Communicable Disease Unit leads all infectious-disease investigations and disease surveillance and also directs emerging-health-threat management and vaccine distribution. The unit consists of medical doctors, registered nurses, and environmental health officers. The Health Protection Unit coordinates the environmental health services. Areas of responsibility include food safety, tobacco control and reduction, drinking-water quality, recreational water quality, air quality, licensing of community care facilities, pest control and pesticide reduction, noise control, housing and general sanitation, and environmental protection and promotion. The Health Protection Unit also participates in communicable-disease surveillance and emergency preparedness. The unit consists of 60 employees, a combination of full-time and part-time environmental health officers and administrative support-staff.

VCHA-Environmental Health

The Health Protection Unit employs 43 environmental health officers whose roles range from management to field work (Figure 1).

A Certificate in Public Health Inspection is required for employment as an environmental health officer. There are five Canadian academic institutions, including the British Columbia Institute of Technology in Burnaby, that provide programs of instruction approved by the governing Board of Certification of Public Health Inspectors. A Bachelor of Technology in Environmental Health prepares students for a career in public/environmental health services. The Bachelor of Technology takes four years to complete and includes 18 months of environmental and public health courses and two 12-week practica. A two-year, fast-track option exists for candidates with existing degrees or certain diplomas. Graduates with a Bachelor of Technology in Environmental Health become certified environmental health officers through testing and certification by the Canadian Institute of Public Health Inspectors (CIPHI).

Within VCHA's Health Protection Unit, environmental health officers work in various programs from food safety to tobacco control (Figure 1). One program aspect not traditionally seen in American public health departments is the integration of the environmental health program into the communicable-disease program. Two environmental health officers are employed by the Health Protection Unit but work within the Communicable Disease Unit; these positions are for a communicable-disease specialist and a communicable-disease environmental health officer.

The communicable-disease specialist coordinates vaccines and the immunization program for influenza, issues tuberculosis orders, and manages emerging health threats. The role of the communicable-disease environmental health officer includes investigating suspect foodborne illnesses. This officer is responsible for collecting disease information, organizing specimen collections during an outbreak, developing and administering questionnaires, collecting laboratory reports, and assisting with other communicable-disease outbreak investigations being conducted by the Communicable Disease Unit.

Assistance also is received from environmental health officers when needed. For example, environmental health officers help with facility-based influenza outbreaks. They assist with distribution and collection of influenza testing kits, working with their contacts in the facility and assisting the facility if it needs to be closed. Other environmental health officers may assist with specimen collection and questionnaire administration.

Environmental health officers receive training for communicable-disease investigations and surveillance through numerous methods. Part of communicable-disease training comes on the job, but Vancouver environmental health officers gain a foundation during their environmental health certification/bachelor of technology courses. The Canadian Institute of Public Health Inspectors offers a continuing-education program on communicable disease. Health Canada also offers online epidemiology courses free of charge to public health officials. Conferences and professional journals provide additional opportunities for communicable-disease education.

VCHA Preparedness Efforts

VCHA environmental health officers are an integral part of emergency response. They are versatile employees who can rely on their extensive experience to adapt to new roles or who can continue their regular services during health emergencies.

Planning

VCHA has two emergency planners, one for the community and one for the hospital. The community emergency planner ensures that the community components of the health care system (e.g., public health nursing, long-term care, home care, and mental health services) are prepared. The hospital emergency planner is responsible for the emergency response plans of British Columbia's trauma care center and ensures that other Vancouver Coastal Health hospitals have their emergency plans ready and tested. The chief medical health officer contributes to emergency response planning at the senior policy level and provides overall leadership for the health authority in the area of preparedness. He coordinates all of the planning for emergency preparedness, including ensuring that a Vancouver Coastal Health Emergency Operations Centre (EOC) is established. The chief medical health officer also sits on the Policy Committee of the city of Vancouver. Emergency response planning is municipally based, but the health region must develop an overall regional response plan to integrate all provincial health authorities.

In 2001 a local working group was formed to develop an exposure-to-biological agents response strategy. The public health system recognized that Vancouver did not have a local response plan for an accidental or planned exposure to biological or chemical agents. The city also worked to respond to the numerous anthrax hoaxes many other cities were struggling to manage effectively. The result of this working group was the Exposure to Biological Agents Response Plan, published in February 2002. As part of the plan, the formation of a bioterrorism response advisory team (BRAT) was recommended to provide technical expertise in identifying and assessing the risk from bioterrorism and biohazards. The BRAT plan outlines the procedures emergency medical responders, hospitals, public health officials, and the provincial laboratory should take in case of a biological-terrorism threat or event. Environmental health officers are specifically tasked with assisting with action items in the local public health response section, including active surveillance, case follow-up, and environmental surety. The response plan has not been updated since its initial release, nor trained on internally, but it is scheduled to be updated soon. Funding has been received from the federal government to add VCHA's smallpox response plan to the BRAT plan. VCHA's pandemic influenza response plan also is being added to the BRAT plan and has been adopted by the province.

The current plan does not address chemical agents, but health officials noted the desire to have a comprehensive chemical, biological, radiological, and nuclear (CBRN) response plan (Bioterrorism Response Advisory Team, 2002).

VCHA joined with other Vancouver first responders to work on a CBRN plan. Included in the planning group are the Vancouver Police Department, Vancouver Fire and Rescue Services, City of Vancouver Environmental Protection Branch, VCHA (both communicable diseases and environmental health), British Columbia Centre for Disease Control, hospitals, emergency management, and British Columbia Ambulance Service. The larger group has developed smaller working groups to broaden the scope of their work and to capitalize on the momentum they have built. They have increased their scope to include training and developing a regional database for resources. The group is in its beginning stages of work, but the communication and relationship building is well under way and will serve the planning process well.

Also mentioned in the Biological Agents Response Plan are the emergency communications center for southwest British Columbia (E-Comm) and the Vancouver Emergency Operations Centre (EOC). E-Comm and EOC are located in the same building. BRAT provides consultation to the Policy Group at the EOC during a biological emergency. During major emergencies, a VCHA environmental health officer is assigned to the EOC to communicate information back to the public health authorities. Depending on the scenario being played out (or the actual emergency) the environmental health officer might be alerting the Community Health component of VCHA to put a care facility on alert for evacuation or to prepare for a situation where drinking water may be either contaminated or in short supply. This relationship already existed long before the threat of bioterrorism rose to the forefront.

Training

VCHA environmental health officers have received training in emergency preparedness. The Canadian Emergency Preparedness College offered a nine-day pilot course in first responder CBRN training in the summer of 2003. Vancouver, along with Toronto and Halifax, sent teams of first responders. Vancouver included an environmental health officer on its team. One course objective was to create multidisciplinary teams to enhance interoperability among response agencies. The training offered basic and intermediate-level modules with information including medical knowledge and response, hazard identification, site management, and casualty management. The training included self-study, classroom sessions, and field exercises. The training also served to start or continue the process of local planning, tabletops, and exercises. The environmental health officer who participated in this training will work with fellow Vancouver CBRN training participants to continue planning efforts and will become the trainer for VCHA employees.

VCHA is dedicated to a 24-hour, seven-day-per-week response capacity for the Vancouver communities. Environmental health supervisors share the duty of being on call for two-week periods. They respond to emergencies as needed or forward the information on to the appropriate parties. In the past, they have responded to foodborne outbreaks, restaurant fires, and hazmat calls. Environmental health officials are called in by Vancouver HAZMAT to assess the effect the hazard may have on the health of the population.

Events

VCHA environmental health officers have had several opportunities over the last few years to participate in emergency response, either in response roles or backing up colleagues who responded and could not continue regular responsibilities. In the spring of 2003, severe acute respiratory syndrome (SARS) arrived in Canada. Vancouver International Airport is a major destination for travelers from many of the nations where SARS was known to be a problem. To limit the number of people with SARS or SARS symptoms entering Vancouver, health officials decided to identify those individuals as soon as they arrived in the airport. Environmental health officers were assigned to the airport to assist with the screening process. Nurses would typically have been used to fill these positions, but there was a shortage of registered nurses because of union disagreement. The environmental health officers helped identify those coming off Asian flights who met the fever criteria set by health officials. A medical health officer coordinated the process at the airport, and teams of health inspectors handed out flyers as passengers and flight staff departed. Another health officer assessed individuals for sickness and retrieved pre-identified people as they exited the gate. People identified as being suspect were transported directly to the hospital. Over time, the teams of health screeners increased at each arriving plane to provide better throughput. Environmental health officers participated in the screenings for approximately three months before the registered nurses replaced them. Upon reflection, the environmental health officers felt that they were able to contribute as health screeners. They understood sterilization and infection control practices and were able to focus their attention in that area. Also, they were experienced at organizing and able to provide recommendations for increased efficiency to minimize the amount of extra time the passengers spent in the gates. Some were multilingual and able to assist with translation. The environmental health officers were familiar with security clearance and able to work under stressful conditions. Overall, they were flexible and able to adjust as the situation changed almost daily.

Another area of emergency preparedness Vancouver environmental health officials are familiar with is maintaining public health responsibilities during an emergency. During the fall of 2003, forest fires affected communities in the interior of British Columbia. The staff of the Interior Health Authority needed to help manage the efforts related to fighting the forest fires and as a result were unable to meet fully their regular requirements. Also, as a result of the fires, a boil-water advisory was in effect for the area. The Interior Health Authority was in need of assistance to do restaurant inspections, especially to make sure that restaurants were adhering to the advisory. VCHA offered assistance after learning of this need; it had environmental health professionals who were both interested in assisting and qualified to assist. A VCHA environmental health officer was dispatched to the community of 100 Mile House to assist with restaurant inspections for a week in September 2003. The inspector's salary was covered by VCHA. The inspection process was not identical to Vancouver inspections but close enough that the environmental health officer was able to catch on quickly and provide needed support.

VCHA Preparedness-Next Steps

The role of public health, including environmental health, in emergency preparedness will continue to expand in Vancouver over time. The CBRN plan will require significant work and collaboration among the various response agencies. The clarification of response roles and associated training will include environmental health professionals and public health.

Vancouver will host the 2010 Winter Olympics and will be required to meet various security requirements before the start of the games. Much of the work being done today will either apply to security requirements for the Olympics or create the necessary partnerships for the work that will need to occur. Planning for the Olympics will enhance the work already being done by Vancouver and solidify the relationship of response agencies beyond the area of emergency response.

Ideas for Application in U.S. Public Health Agencies

The use of VCHA's environmental health professionals in preparedness for both large-scale and everyday emergencies provides several examples of how environmental health professionals can be utilized in emergency preparedness in the United States.

Environmental health professionals should be involved in developing both internal and external response plans. They know their capabilities and can recommend when their skills would be useful. This process would also educate other planners about environmental health capabilities and responsibilities. Also, the contacts environmental health has in the first-responder community will help build bridges between public health and the rest of the response community.

It is also worthwhile to have environmental health professionals working with local hazmat teams to make each aware of the other's capabilities and responsibilities. Environmental health professionals can be a valuable link between first responders, potential health hazards, and the local health department. While an environmental health officer need not be present on every call, having the hazmat team aware of public health responsibilities and its capacity to help when hazards may affect a population's health would be highly beneficial. These everyday relationships are invaluable in the planning efforts and during large emergencies. This observation also relates to the 24/7 response capability of VCHA's environmental health officers. This capacity instills a sense of the emergency response culture in public health staff before a large-scale emergency happens. It also establishes credibility with the community and response partners and demonstrates that VCHA is a first responder.

In the United States, local health department staff with clinical experience typically have the primary responsibility of responding to infectious-disease outbreaks. Vancouver's use of environmental health officers in enteric- and emerging-disease investigations and surveillance and to increase surge capacity for communicable-disease staff is an example of a good way to improve health department response capability. The Vancouver environmental health officers have numerous opportunities to learn about communicable-disease control and epidemiology. They receive formal education while working toward their certificate, training through professional organizations, and on-the-job training from communicable-disease staff. The environmental health officers also are able to adapt quickly to new situations. This routine use of environmental health officers in communicable-disease response makes an organization much more flexible in responding to a large-scale outbreak or public health emergency. The epidemiology capability provides VCHA with tremendous response capacity.

Finally, VCHA offers support in regional emergencies by providing backup to provincial public health partners when their staff is stretched thin. This is an important aspect of emergency planning and response: the ability to carry out regular public health responsibilities while also responding to emergencies. It is important for health departments to consider mutual aid while developing response plans and when responding to emergencies.

Conclusion

The experience of VCHA and its integrated approach to emergency preparedness clearly show the value of communication and cooperation among public health agencies. By using systematic training opportunities and deploying environmental health officers as first responders, VCHA has successfully developed a flexible model for responding to public health emergencies in an area of overlapping jurisdictions and simultaneously has created valuable extra epidemiological capacity. American public health agencies can learn a great deal from them.

Acknowledgements: Work was made possible by support from NEHA and CIPHI, and by funding from NSF International and Underwriters Laboratories, Inc. Special thanks go to the Vancouver Coastal Health Authority for its generosity and hospitality. Also, the author thanks her colleagues at the DeKalb County, Georgia, Board of Health and its Center for Public Health Preparedness for their support throughout the sabbatical process.

Editor's note: The author of this special report was a participant in the NEHA/Canadian Institute of Public Health Inspectors (CIPHI) sabbatical exchange program. The overall goal of the sabbatical was to learn how a local Canadian government agency integrates environmental health professionals into planning, training, and responding to potential public health emergencies.

NEHA offers two sabbaticals--one to England, in cooperation with the Chartered Institute of Environmental Health, and the other to Canada, in cooperation with CIPHI. For more information on the sabbatical exchange program, please visit www.neha.org/about/awardinfo.html.

References

Bioterrorism Response Advisory Team, City of Vancouver. (2002). Exposure to biological agents response plan. www.bccdc.org/downloads/pdf/lab/reports/BRATPlan2002Feb.pdf (12 Apr. 2004).

Lyman, F. (2003). Messages in the dust: Lessons learned, post-9/11, for environmental health. Journal of Environmental Health, 66(5), 30-37.

Sara L. Forsting, M.S.P.H.

Corresponding Author: Sara Forsting, Epidemiologist, DeKalb Advanced Practice Center, Center for Public Health Preparedness DeKalb County Board of Health, 445 Winn Way, Ste. 557, Decatur, GA 30030. E-mail: [e-mail].