Table of Contents 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64

NEHA March 2023 Journal of Environmental Health

JOURNAL OF f i f t e e n d o l l a r s Environmental Health Published by the National Environmental Health Association www.neha.org Dedicated to the advancement of the environmental health professional Volume 85, No. 7 March 2023

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March 2023 • Journal of Environmental Health 3 ADVANCEMENT OF THE SCIENCE Assessment of Chemical Exposures Investigation After Fire at an Industrial Chemical Facility in Winnebago County, Illinois........................................................................ 8 The COVID-19 Pandemic, Fukushima Nuclear Disaster, and Commonalities and Public Health Threat Complexities: A Public Health, Healthcare, and Emergency Management Command and Support Supersystem Model..................................... 16 ADVANCEMENT OF THE PRACTICE Identifying Public Perceptions of Information on Harmful Algal Blooms to Guide Effective Risk Communication................................................................................... 26 Direct From AEHAP: From Assessment to Action: A Road Map to Becoming an Environmental Health Science Professional............................................................................. 32 Direct From CDC/Environmental Health Services: Community Resources for Contaminants of Concern in Private Wells.............................................................................. 36 Direct From ecoAmerica: The Climate World Is Changing, So Can We....................................... 40 NEW Environmental Health Across the Globe: How an Australian Centre for Disease Control Can Reinforce Environmental Health Systems and Services............................ 42 Programs Accredited by the National Environmental Health Science and Protection Accreditation Council. ...................................................................................... 45 ADVANCEMENT OF THE PRACTITIONER Environmental Health Calendar................................................................................................ 46 Resource Corner........................................................................................................................ 47 JEH Quiz #5............................................................................................................................... 48 YOUR ASSOCIATION President’s Message: Join the Fliers Who Soar to Great Heights. .............................................................6 NEHA Second Vice-Presidential Candidate Profile. .................................................................. 49 Special Listing............................................................................................................................ 50 NEHA Regional Vice-Presidential Candidate Profiles................................................................ 52 NEHA News............................................................................................................................... 54 NEHA 2023 AEC....................................................................................................................... 60 NEHA Member Spotlight........................................................................................................... 62 JOURNAL OF Environmental Health Dedicated to the advancement of the environmental health professional Volume 85, No. 7 March 2023 A B O U T T H E C O V E R Accurate, understandable, and reliable information is crucial during and after a harmful algal bloom (HAB) event. This month’s cover article, “Identifying Public Perceptions of Information on Harmful Algal Blooms to Guide Effective Risk Communication,” examined perceptions of residents near Lake Erie’s western basin about where they received HAB information, what information was most important, and which sources they found most credible. Results from the study highlight that effective risk communication should provide information about severe events in an understandable and timely manner, convey unbiased facts, deliver information from sources seen as trustworthy, and use existing opportunities in the community to provide education. See page 26. Cover image © iStockphoto: ansonsaw, wichatsurin A D V E R T I S E R S I N D E X Awards and Scholarships...................... 5, 39, 57, 63 Custom Data Processing......................................... 7 Environmental Health and Land Reuse Certificate Program............................................... 39 GOJO Industries..................................................... 2 HS GovTech.......................................................... 64 JEH Advertising..................................................... 49 NEHA Credentials. ................................... 35, 38, 53 NEHA Endowment and Scholarship Funds. .. 25, 31 NEHA Membership. ................................... 4, 15, 59

4 Volume 85 • Number 7 in the next Journal of Environmental Health don’t miss Of f i c i a l Pub l i ca t i on Journal of Environmental Health (ISSN 0022-0892) Kristen Ruby-Cisneros, Managing Editor Ellen Kuwana, MS, Copy Editor Hughes design|communications, Design/Production Cognition Studio, Cover Artwork Soni Fink, Advertising For advertising call (303) 802-2139 Technical Editors William A. Adler, MPH, RS Retired (Minnesota Department of Health), Rochester, MN Gary Erbeck, MPH Retired (County of San Diego Department of Environmental Health), San Diego, CA Thomas H. Hatfield, DrPH, REHS, DAAS California State University, Northridge, CA Dhitinut Ratnapradipa, PhD, MCHES Creighton University, Omaha, NE Published monthly (except bimonthly in January/February and July/ August) by the National Environmental Health Association, 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Phone: (303) 8022200; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 85, Number 7. Yearly subscription rates in U.S.: $150 (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/jeh. Claims must be filed within 30 days domestic, 90 days foreign, © Copyright 2023, National Environmental Health Association (no refunds). All rights reserved. Contents may be reproduced only with permission of the managing editor. Opinions and conclusions expressed in articles, columns, and other contributions are those of the authors only and do not reflect the policies or views of NEHA. NEHA and the Journal of Environmental Health are not liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein. NEHA and theJournal of Environmental Health reserve the right to reject any advertising copy. Advertisers and their agencies will assume liability for the content of all advertisements printed and also assume responsibility for any claims arising therefrom against the publisher. The Journal of Environmental Health is indexed by Clarivate, EBSCO (Applied Science & Technology Index), Elsevier (Current Awareness in Biological Sciences), Gale Cengage, and ProQuest. The Journal of Environmental Health is archived by JSTOR (www.jstor.org/journal/ jenviheal). All technical manuscripts submitted for publication are subject to peer review. Contact the managing editor for Instructions for Authors, or visit www.neha.org/jeh. To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, kruby@neha.org. Periodicals postage paid at Denver, Colorado, and additional mailing offices. POSTMASTER: Send address changes to Journal of Environmental Health, 720 S. Colorado Blvd., Suite 105A, Denver, CO 80246-1910. Printed on recycled paper.  Bacterial Contamination in Long Island Sound: Using Preemptive Beach Closure to Protect Public Health  Decreased Moderate to Vigorous Physical Activity Levels Are Associated With Increased Traffic-Related Air Pollutants in Children With Asthma  Effectively Communicating Results of Drinking Water Tests From Private Wells Join our environmental health community. It is the only community of people who truly understand what it means to do what you do every day to protect the health of our communities. Join us today. Your people are waiting. neha.org/membership Find Your People. Find Your Training. Find Your Resources.

March 2023 • our5(l o- 5=0ro5me5;(l e(l;/ 5 Do you know someone who is walking the walk? When your colleague or team steps up to create a more just, diverse, equitable, and inclusive environment, it matters! Let them know by nominating them today for the Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award. Nomination Deadline: May 15, 2023 neha.org/awards Dr. Bailus Walker, Jr. Diversity and Inclusion Awareness Award Recognize your colleague! Do you work with someone who is always coming up with creative ways to educate the public or colleagues? Is there someone on your team who has created tools or a practice that has really made a difference in improving environmental health? Nominate them for the Joe Beck Educational Contribution Award and show them how much you value their contribution. Nomination Deadline: May 15, 2023 neha.org/awards Joe Beck Educational Contribution Award

6 Volume 85 • Number 7 YOUR ASSOCIATION D. Gary Brown, DrPH, CIH, RS, DAAS Join the Fliers Who Soar to Great Heights  PRES I DENT ’ S MESSAGE The quote by Marty Rubin, “The deep roots never doubt spring will come,” is a reminder even in the season of renewal that the current season of bloom for the National Environmental Health Association (NEHA) is from the environmental health trail blazers who sowed the initial seeds. In this column I want to highlight two groups—the American Academy of Sanitarians (AAS) and the NEHA History Project Task Force—that many associate with the foundation or roots of environmental health. Being around these amazing people reminds me of what Pelé said, “Success is no accident. It is hard work, perseverance, learning, studying, sacrifice, and most of all, love of what you are doing or learning to do.” I cannot begin to express my gratitude for all the work done by these distinguished groups whose energy is infectious. I have the pleasure and honor of being a member of both organizations where I have gained knowledge, fellowship, friendship, and joy. As Michelangelo said, “I am still learning.” Furthermore, Antoine de SaintExupéry stated, “The tree is more than first a seed, then a stem, then a living trunk, and then dead timber. The tree is a slow, enduring force straining to win the sky.” If our environmental health pioneers are the roots of the tree, mid-career professionals are the trunk and early career professionals are the leaves. A tree (e.g., NEHA) does not flourish unless all parts of the tree are working together. The bursting petals of the new NEHA logo represent a new era and excitement for what is possible for NEHA and our profession. NEHA shares the idea stated by Eleanor Roosevelt: “The future belongs to those who believe in the beauty of their dreams.” AAS is an organization that elevates standards, improves the practice, advances professional proficiency, and promotes the highest levels of ethical conduct in every field of environmental health. Many environmental health professionals do not realize that AAS sponsors the Davis Calvin Wagner Sanitarian Award, which is conferred for exceptional leadership ability, professional commitment, outstanding resourcefulness, dedication, and accomplishments in advancing the sanitarian profession and public health programs. In addition, AAS is one of the many cosponsors of the Samuel J. Crumbine Consumer Protection Award (https://crumbineaward. com). The Crumbine Award is a prestigious national award given annually to local environmental health jurisdictions that demonstrate excellence and continual improvement in a comprehensive food protection program. The purpose of the Crumbine Award is to encourage improvement and stimulate public interest in food service sanitation. AAS has supported early career and student members since its inception. Through a partnership between NEHA and AAS, annual educational scholarships are awarded to exceptional undergraduate and graduate students pursuing a career in environmental health. AAS also helps to enhance student experiences at the NEHA Annual Educational Conference (AEC) & Exhibition. Becoming a diplomate in AAS denotes a high standard of professionalismwith marked distinction and a record of accomplishment in environmental health. It denotes professional status and gives prestige to the holders of the diplomate certification. AAS invites and encourages professionally credentialed environmental health practitioners with qualities of outstanding competence and leadership to become certified as diplomates. Currently, there are thousands of registered environmental health specialist/registered sanitarian (REHS/RS) professionals, but since the inception of AAS in 1966, only 611 environmental health professionals have been awarded diplomate status. Becoming a diplomate helps you stand out from the crowd, enhancing your career while promoting the profession. Join the di™erence makers! As Jane Goodall stated, “What you do makes a di™erence and you have to decide what kind of di™erence you want to make.” To become a member of this prestigious group you must hold an REHS or RS credential, have three reference letters, have at least one published paper, and demonstrate to the The current season of bloom for NEHA is from the environmental health trail blazers who sowed the initial seeds.

March 2023 • Journal of Environmental Health 7 satisfaction of the AAS board your good moral character and high ethical and professional standing. For further information, please visit the AAS website at https://aaosi.wildapricot.org. In 2020, NEHA President Dr. Priscilla Oliver, the founder of the One NEHA theme, started the NEHA History Project Task Force, which is composed of a group of illustrious NEHA professionals who have made numerous contributions to our field. I have had the privilege and honor of being an ex-officio member of this task force. The NEHA History Project Task Force accomplishments include launching a webpage in 2021, led by Kristen Ruby-Cisneros, managing editor of the Journal of Environmental Health, to showcase its work and NEHA’s history (www.neha.org/history). The NEHA History Project webpage provides an overview of the project and a list of task force members and how to get involved. Other highlights from the NEHA History Project webpage include: • An electronic version of the NEHA Green Book: Environmental Health 1937–1987, Fifty Years of Professional Development With the National Association of Sanitarians/ National Environmental Health Association was published in 1987 by NEHA and provides a brief history of the first 50 years of the association. The task force, led by Dr. Hermen Koren, is developing a new and updated publication on the history of NEHA and the profession. • NEHA Virtual Museum: We have posted images and descriptions of artifacts, instrumentation and tools, publications, and miscellaneous items related to environmental health and NEHA from the personal collection of Dr. Robert Powitz. • A listing of past NEHA AECs: You can learn about where our past AECs have been held and peruse links to the reports published in the Journal of Environmental Health about each conference. Dr. Leon Vinci has been a great chairperson keeping us on target. The task force has included distinguished individuals from academia such as Dr. Jack Hatlen and Dr. Herman Koren. Several NEHA past presidents have served on the task force, including Bob Custard, Diane Eastman, Dr. Amer El-Ahraf, Harry Grenawitzke, Dr. Priscilla Oliver, Dick Pantages, Vince Radke, Dr. Welford Roberts, and Dr. Chris Wiant. Retired RADM Webb Young represents the uniformed services and Drs. Robert Powitz and Leon Vinci represent the private sector. Rounding out the committee in an ex-officio capacity (along with me) are NEHA Executive Director Dr. David Dyjack and Kristen Ruby-Cisneros. The NEHA History Project Task Force states it best: “All forms of input, ideas, and history are welcomed, and we invite you to share that with the task force. The task force also encourages individuals to reach out if interested in joining our work in preserving and presenting the history of NEHA and our profession.” Please become involved with NEHA on a local, state, or national level by spreading the word that environmental health is public health. In doing so, it can be as Dr. Seuss said, “You’ll be on your way up! You’ll be seeing great sights! You’ll join the high fliers who soar to high heights.” gary.brown@eku.edu Environmental health solutions since 1983 CUSTOMIZE. REDUCE COSTS. IMPROVE ACCURACY. www.cdpehs.com (800) 888-6035 Inspections | Permits | Reporting | Scheduling | Online Bill Pay | On/Offline Mobility

8 Volume 85 • Number 7 A D VANC EME N T O F T H E SCIENCE Introduction On the morning of June 14, 2021, a fire ignited and spread rapidly through an industrial chemical facility owned by the largest industrial grease manufacturer in the U.S. and located on the Beloit Corporation Superfund site (U.S. Environmental Protection Agency [U.S. EPA], 2022a) in Winnebago County, Illinois (2020 population: 285,350; U.S. Census Bureau, n.d.). The fire created a dark plume of smoke visible by satellite imagery; required specialized firefighting services; and released smoke, dust, and debris for 4 days. Local authorities issued a 1-mi evacuation order and a 3-mi masking advisory during this time to assist mitigation of potential negative health outcomes in the nearby communities. The available air sampling data from the U.S. Environmental Protection Agency demonstrated several 2.5 micron (PM2.5) and 10 micron (PM10) measurements above the World Health Organization public health screening levels (World Health Organization and Environmental Health Team, 2006); the Illinois Department of Public Health and the Agency for Toxic Substances and Disease Registry (ATSDR) determined that no measurements above the public health screening levels were found for other analytes monitored, including volatile organic compounds, carbon monoxide, oxygen, and hydrogen sulfide (Illinois Environmental Protection Agency, 2022; U.S. EPA, n.d.). Because additional chemical exposures, such as exposures to heavy metals, were unknown, public health authorities considered how to determine the health ešects of the chemicals released from the fire in nearby communities and among first responders, who could have had dišerent exposure experiences than the general population. After a chemical exposure incident, ATSDR evaluates the need to conduct an Assessment of Chemical Exposures (ACE) investigation, which is an epidemiological assessment that can provide information to assess the health ešects of the incident on individuals and communities, direct the public health response, focus outreach to prevent similar incidents, assess the need for modification of emergency response procedures, and identify groups of people who might need long-term follow-up (Agency b: ; r (* ; After a chemical fire, an investigation assessed health e ects by using syndromic surveillance to monitor emergency department (ED) visits, a general health survey to assess the general public, and a first responders health survey to assess first responders. A total of four separate multivariable logistic regression models were developed to examine associations between reported exposure to smoke, dust, debris, or odor with any reported symptom in the general public. Syndromic surveillance identified areas with increased ED visits. Among general health survey respondents, 45.1% (911 out of 2,020) reported at least one symptom. Respondents reporting exposure to smoke, dust, debris, or odor had 4.5 (95% confidence interval (CI) [3.7, 5.5]), 4.6 (95% CI [3.6, 5.8]), 2.0 (95% CI [1.7, 2.5]), or 5.8 (95% CI [4.7, 7.3]) times the odds of reporting any symptom compared with respondents not reporting exposure to smoke, dust, debris, or odor, respectively. First responders commonly reported contact with material and being within 1 mi of the fire ≥5 hr; 10 out of 31 of first responders reported at least one symptom. There was high symptom burden reported after the fire. Results from our investigation might assist the directing of public health resources to e ectively address immediate community needs and prepare for future incidents. Jasmine Y. Nakayama, PhD Krishna Surasi, MD Epidemic Intelligence Service, Centers for Disease Control and Prevention Lance R. Owen, PhD Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry Mark Johnson, PhD Office of Community Health Hazard Assessment, Agency for Toxic Substances and Disease Registry Sandra Martell, DNP Abigail Kittler Peter Lopatin, MBA Winnebago County Health Department Sarah Patrick, PhD Illinois Department of Public Health Caitlin Mertzlufft, PhD Office of Community Health Hazard Assessment, Agency for Toxic Substances and Disease Registry D. Kevin Horton, DrPH Maureen Orr, MS Office of Innovation and Analytics, Agency for Toxic Substances and Disease Registry Assessment of Chemical Exposures Investigation After Fire at an Industrial Chemical Facility in Winnebago County, Illinois

March 2023 • our5(l o- 5=0ro5me5;(l e(l;/ 9 for Toxic Substances and Disease Registry [ATSDR], 2016; Duncan, 2014). On June 25, 2021, the Illinois Department of Public Health invited ATSDR to conduct an ACE investigation (Surasi et al., 2021). This article presents findings from the ACE investigation of a chemical fire in Winnebago County, Illinois. The investigation included several public health tools to examine the magnitude, geography, and nature of the health e‹ects of the fire in nearby communities and assessed exposures and health outcomes among first responders. Methods This ACE investigation used syndromic surveillance to monitor emergency department (ED) visits, a general health survey to assess the general public, and a first responders health survey to assess first responders. Syndromic Surveillance State health departments have access to the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE), a syndromic surveillance program that monitors counts of reasons for ED visits (i.e., chief complaints) (Burkom et al., 2021; Centers for Disease Control and Prevention, 2022). The ESSENCE program incorporates statistical methods to detect anomalies in data and provides alerts and warnings that can guide e‹orts to determine if the trends require further attention or intervention. ESSENCE was used to monitor trends in ED visits during the month after the incident, map ZIP Code areas with the largest numbers of ED visits, and specify which chief complaints (e.g., respiratory, mental health) increased in these areas. As the facility was near the Wisconsin border, the Wisconsin Department of Health Services also queried ESSENCE using the same criteria for ED visits related to the fire during June 14–July 1, 2021. General Health Survey Using a general health survey to assess the general public, the investigation team examined the association of residents’ reported contact with material (i.e., smoke, dust, debris) or report of smelling an odor with any reported new or worsening symptom within the 2 weeks prior to survey completion. The investigation team designed an electronic survey that was adapted from survey forms available from ATSDR’s ACE Toolkit (ATSDR, 2014; Duncan & Orr, 2016) and Epi Contact Assessment Symptom Exposure (Epi CASE) Toolkit (ATSDR, 2020) to evaluate the human health e‹ects of the fire in the nearby population. The survey asked about demographic characteristics, residential distance from the facility, contact with material, smelling an odor, healthcare use, and new or worsening symptoms within the 2 weeks prior to survey completion. Demographic characteristics included age, gender, race, and ethnicity. Age was calculated from date of birth and categorized as 0–19, 20–44, 45–64, and ≥65. Respondents selected one option for gender: female, male, transgender, or other. Respondents selfreported race from a list of options (White, Black or African American, Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, Other) and were considered “Multiracial” if they selected more than one Characteristics of General Health Survey Respondents by Symptom Status and Overall and Characteristics of the General Population From 11 ZIP Codes, Winnebago County, Illinois, July 2021 Characteristic Asymptomatic Respondents (n = 1,109) # (%) Symptomatic Respondents (n = 911) # (%) Respondents Overall (N = 2,020) # (%) General Population From 11 ZIP Codes (N = 240,043) # (%) Age (years) 0–19 17 (1.5) 11 (1.2) 28 (1.4) 61,626 (25.7) 20–44 370 (33.4) 363 (39.8) 733 (36.3) 72,678 (30.3) 45–64 492 (44.4) 400 (43.9) 892 (44.2) 64,305 (26.8) ≥65 225 (20.3) 135 (14.8) 360 (17.8) 41,434 (17.3) Missing 5 (0.5) 2 (0.2) 7 (0.3) – Gender or Sex a Female 664 (59.9) 613 (67.3) 1,277 (63.2) 123,580 (51.5) Male 431 (38.9) 272 (29.9) 703 (34.8) 116,463 (48.5) Transgender 1 (0.1) 5 (0.5) 6 (0.3) – Other 1 (0.1) 5 (0.5) 6 (0.3) – Prefer not to answer 12 (1.1) 16 (1.8) 28 (1.4) – Race White 967 (87.2) 777 (85.3) 1,744 (86.3) 188,983 (78.7) Black or African American 25 (2.3) 40 (4.4) 65 (3.2) 30,516 (12.7) Other 21 (1.9) 21 (2.3) 42 (2.1) 4,396 (1.8) Asian 31 (2.8) 9 (1.0) 40 (2.0) 7,291 (3.0) Multiracial 15 (1.4) 12 (1.3) 27 (1.3) 8,075 (3.4) American Indian or Alaska Native 2 (0.2) 6 (0.7) 8 (0.4) 757 (0.3) Native Hawaiian or Pacific Islander 0 (0) 0 (0) 0 (0) 25 (<0.1) Prefer not to answer 48 (4.3) 46 (5.0) 94 (4.7) – Hispanic or Latino No 1,064 (95.9) 855 (93.9) 1,919 (95.0) 209,996 b (87.5) Yes 45 (4.1) 56 (6.1) 101 (5.0) 30,047 (12.5) TABLE 1 continued on page 10

10 Volume 85 • Number 7 A D VANC EME N T O F T H E SCIENCE race. Respondents indicated whether they were Hispanic or Latino. The distribution of age, gender or sex, race, and ethnicity was compared between survey respondents and the entire population of the 11 ZIP Codes of interest using estimates from the American Community Survey 5-Year Data 2019 (U.S. Census Bureau, 2021). Residential addresses of survey respondents were geocoded at the census tract level. Their residential distance from the facility was calculated using Esri’s ArcGIS Pro desktop application, and respondents were categorized as living <1, 1 to <3, 3 to <5, 5 to <10, 10 to <15, or ≥15 mi from the facility. Geospatial analyses used data from the Social Vulnerability Index (SVI), in which a higher quartile indicates higher social vulnerability (i.e., a community’s susceptibility to negative e–ects from disasters) than a lower quartile (ATSDR, 2022). The survey asked about contact with material and respondents chose all that applied: smoke, dust, debris, other, none, or unsure. Respondents also indicated if they smelled an odor. The survey then asked about the highest level of healthcare received because of the incident: formal healthcare services (i.e., hospitalization; visit to an ED, urgent care center, or outpatient clinic; or telehealth consult), self-treatment, or no healthcare needed. The survey asked, “Over the past 2 weeks since the event have you experienced worsening of a preexisting or a new onset of any of the following symptoms?” and allowed respondents to select all that applied from a list of symptoms organized by category: ears, nose, and throat (ENT); neurological; ophthalmic; cardiopulmonary; psychiatric; and skin. Respondents reporting a new or worsening symptom within the 2 weeks prior to survey completion were categorized as symptomatic and all others as asymptomatic. Among symptomatic respondents, it was determined which symptoms were reported, how many symptoms were reported, and how many symptom categories were involved. The survey was administered by leveraging the Qualtrics XM Platform client engagement system, which is an existing system that was used for COVID-19 vaccination registration. The survey was publicly available July 1–15, 2021, and residents could access it through a link shared via news outlets, social media, and the local health department website. Additionally, on July 5, the Qualtrics system was used to send the survey link to 40,217 email addresses of registered residents from 11 ZIP Codes of interest (5 identified through surveillance data and 6 nearby ones) and it was noted whether a respondent accessed the survey through the email link. On July 12, the survey link was emailed to registered residents of a neighboring Wisconsin county. Survey data were analyzed in R software (version 4.1.0) and a response was excluded if it was a duplicate entry, the residential addresses did not geocode, it was missing symptom data, or it was from a first responder. Duplicate entries were determined by identifying duplicate unique identifiers created by the Qualtrics system; the earliest entry was included and subsequent entries with the same unique identifier were excluded. Additionally, geospatial analysis was conducted to visualize the distribution of respondents reporting any symptom. Frequencies were calculated for reported demographic characteristics, residential distance from the facility, healthcare use, contact with material, smelling an odor, and symptoms for residents from the general public responding to the general health survey. Multivariable logistic regresCharacteristics of General Health Survey Respondents by Symptom Status and Overall and Characteristics of the General Population From 11 ZIP Codes, Winnebago County, Illinois, July 2021 TABLE 1 continued from page 9 Characteristic Asymptomatic Respondents (n = 1,109) # (%) Symptomatic Respondents (n = 911) # (%) Respondents Overall (N = 2,020) # (%) General Population From 11 ZIP Codes (N = 240,043) # (%) Residential distance from the facility <1 mi 26 (2.3) 92 (10.1) 118 (5.8) – 1–<3 mi 140 (12.6) 175 (19.2) 315 (15.6) – 3–<5 mi 86 (7.8) 90 (9.9) 176 (8.7) – 5–<10 mi 233 (21.0) 177 (19.4) 410 (20.3) – 10–<15 mi 438 (39.5) 280 (30.7) 718 (35.5) – ≥15 mi 186 (16.8) 97 (10.6) 283 (14.0) – Healthcare use No healthcare needed 1,096 (98.8) 451 (49.5) 1,547 (76.6) – Self-treated 8 (0.7) 347 (38.1) 355 (17.6) – Consulted a healthcare professional via phone or video conferencing 3 (0.3) 45 (4.9) 48 (2.4) – Visited an emergency department, urgent care, or outpatient clinic 0 (0) 57 (6.3) 57 (2.8) – Hospitalized 0 (0) 4 (0.4) 4 (0.2) – Missing 2 (0.2) 7 (0.8) 9 (0.4) – Note. Data include survey respondents of the general health survey and exclude first responders. General population data were obtained from the American Community Survey 5-Year Data 2019. a Survey respondents self-identified their gender. The American Community Survey 5-Year Data 2019 presents proportions for sex. b The non-Hispanic or Latino proportion of the general population was calculated by subtracting the number of Hispanic or Latino proportion from the total population.

March 2023 • Journal of Environmental Health 11 sion was applied to assess the association of contact with material or smelling an odor with the outcome of symptom status (symptomatic versus asymptomatic) among residents from the general public. Four separate models were developed with symptom status as the dependent variable and contact with smoke, contact with dust, contact with debris, or smelling an odor as the main exposure variable—and were adjusted for age, gender, race, ethnicity, and residential distance from the facility. First Responders Health Survey Although the general health survey was available to the general public, a separate health survey was later developed specifically for first responders that had nearly identical questions. Because it was suspected that first responders did not want to be identified on the general health survey because of fear of professional consequences, the first responders survey did not require them to enter identifying information to complete it. Local police and fire chiefs shared the survey link through internal professional communication channels. First responders who completed the first responders health survey and respondents who completed the general health survey (e.g., before the first responders health survey was available) and self-identified as first responders were grouped together. Frequencies were calculated for reported demographic characteristics, use of personal protective equipment (PPE), contact with material, smelling an odor, symptoms, and healthcare use for first responders. No inferential statistical tests for first responders were performed because of small sample size. This activity was reviewed by the Centers for Disease Control and Prevention (CDC) and was conducted consistent with applicable federal law and CDC policy. Results Syndromic Surveillance ESSENCE syndromic surveillance data identified 15% more ED visits than baseline on the day of the incident in the county, and the number declined within the week. Mapping the area around the facility, the team identified 6 ZIP Code areas downwind of the facility with the largest number of ED visits. Among residents in those 6 ZIP Code areas, ESSENCE data showed alerts and warnings for specific chief complaints compared with the previous 90-day baseline. Chief complaints for respiratory symptoms increased on June 14, and chief complaints for asthma increased on June 17. Chief complaints for disasterrelated mental health increased on June 15, and chief complaints related to self-harm increased on multiple days. Continued trends in ESSENCE 1 month after the incident were not identified. The ESSENCE query conducted by the Wisconsin Department of Health Services resulted in 17 unique results for individuals visiting the ED from June 15–24; further, 6 of the results had a direct reference to the chemical fire for the chief complaint. None of the individuals was admitted for a higher level of care. General Health Survey From an initial 2,053 responses, 2 duplicate entries, 17 responses with residential Kernel Density Map of General Health Survey Respondents Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion, Winnebago County, Illinois, July 2021 Note. Data include survey respondents of the general health survey and exclude first responders. CDC/ATSDR = Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry. FIGURE 1

12 Volume 85 • Number 7 A D VANC EME N T O F T H E SCIENCE addresses that did not geocode, 4 responses that were missing symptom data, and 10 responses from first responders were excluded, resulting in an analytic sample of 2,020. Overall, 911 (45.1%) of respondents reported experiencing at least one new or worsening symptom within the 2 weeks prior to survey completion. Characteristics of respondents by symptom status and respondents overall, along with demographic characteristics of the general population from 11 ZIP Codes, are shown in Table 1. Figure 1 presents a map of the distribution of symptomatic respondents using a magnitude-per-unit-area visualization. Only 91 responses were completed between July 1–5; on July 6 and 7, an additional 860 and 630 responses were completed, respectively. Among symptomatic respondents, 80.6% (734 out of 911) accessed the survey through the email link, and among asymptomatic respondents, 96.1% (1,066 out of 1,109) used the email link to access the survey. Analysis indicated fewer survey responses and fewer reports of using formal healthcare services in census tracts with the highest SVI quartile compared with census tracts with lower SVI quartiles in a nearby city. A total of 1,225 (60.6%) respondents reported contact with any material, with 965 (78.8%), 498 (40.7%), 690 (56.3%), and 47 (3.8%) of them reporting contact with smoke, dust, debris, and other material, respectively. A total of 1,047 (51.8%) respondents reported smelling an odor. Table 2 presents adjusted odds ratios for four separate models with reported symptom status as the outcome variable and di–erent exposure variables (i.e., contact with smoke, contact with dust, contact with debris, or smelling an odor), adjusting for age, gender, race, ethnicity, and residential distance from the facility. Among the 911 symptomatic respondents, 635 (69.7%) reported any ENT symptom, 477 (52.4%) reported any neurological symptom, 380 (41.7%) reported any ophthalmic symptom, 302 (33.2%) reported any cardiopulmonary symptom, 237 (26.0%) reported any psychiatric symptom, and 99 (10.9%) reported any skin symptom. Among symptomatic respondents, the median number of symptoms was 4 (interquartile range: 2–6) and the median number of symptom catGeneral Health Survey Respondents Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion for Commonly Reported Symptoms, Winnebago County, Illinois, July 2021 Symptom Symptom Category Respondents Reporting Symptom (N = 2,020) # (%) Headache Neurological 449 (22.2) Stuffy nose or sinus congestion ENT 384 (19.0) Increased congestion or phlegm (mucus) ENT 309 (15.3) Irritation, pain, or burning in eyes Ophthalmic 280 (13.9) Burning nose or throat ENT 267 (13.2) Runny nose ENT 250 (12.4) Anxiety Psychiatric 208 (10.3) Coughing Cardiopulmonary 207 (10.2) Increased watering or tearing Ophthalmic 199 (9.9) Hoarseness ENT 198 (9.8) Dizziness or lightheadedness Neurological 181 (9.0) Difficulty breathing or feeling out-of-breath Cardiopulmonary 139 (6.9) Tension or nervousness Psychiatric 129 (6.4) Asthma Cardiopulmonary 105 (5.2) Fatigue or tiredness Psychiatric 104 (5.1) Difficulty sleeping (e.g., falling asleep, staying asleep) Psychiatric 100 (5.0) Note. Data include survey respondents of the general health survey and exclude first responders. The table includes only symptoms reported by ≥100 respondents. Respondents were able to report more than one symptom. ENT = ears, nose, and throat. Adjusted Odds Ratio Associated With General Health Survey Respondents Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion for Four Separate Models With Different Exposure Variables, Winnebago County, Illinois, July 2021 Exposure Group Adjusted OR 95% CI Contact with smoke versus no contact with smoke 4.5 [3.7, 5.5] Contact with dust versus no contact with dust 4.6 [3.6, 5.8] Contact with debris versus no contact with debris 2.0 [1.7, 2.5] Smelling an odor versus not smelling an odor 5.8 [4.7, 7.3] Note. Data include survey respondents of the general health survey and exclude first responders. The four separate models are adjusted for age, gender, race, ethnicity, and residential distance from the facility. A total of six respondents with missing age data were removed from all four models. Furthermore, a total of 252 respondents were unsure about smelling an odor and were removed from the model with smelling an odor as the exposure variable. CI = confidence interval. TABLE 2 TABLE 3

March 2023 • our5(l o- 5=0ro5me5;(l e(l;/ 13 egories involved was 2 (interquartile range: 1–3). Symptoms reported by ≥100 respondents are listed in Table 3. Among symptomatic respondents, 106 (11.6%) used formal healthcare services and 347 (38.1%) selftreated. Four respondents who used formal healthcare services were hospitalized and the reported indications for admission were asthma (n = 2), epistaxis (n = 1), and one unknown indication. First Responders Health Survey Representing 14 di‹erent organizations, 31 first responders completed the surveys (10 from the general health survey and 21 from the first responders health survey). One first responder self-identified as female and the rest self-identified as male. Further, 28 first responders self-identified as White, 1 selfidentified as Black or African American, 1 self-identified as Other for race, and 1 first responder was missing race data. Furthermore, 2 first responders self-identified as Hispanic or Latino, 1 was missing ethnicity data, and the remaining self-identified as non-Hispanic or Latino. Moreover, 19 first responders reported wearing standard fire protection gear (i.e., fire helmet, turnout pants and jacket, leather gloves, and boots); 3 first responders reported wearing a mask; and 7 first responders reported not wearing a mask, gloves, goggles, hazmat suit coveralls, or standard fire protection gear. Further, 7 first responders reported spending ≤4 hr, 17 reported spending 5–23 hr, 5 reported spending ≥24 hr, and 2 were missing data on time spent within 1 mi of the facility. Only 2 first responders reported not contacting any material; 26, 19, 19, and 5 reported contact with smoke, dust, debris, and other material, respectively. And lastly, 26 first responders reported smelling an odor, 4 were unsure whether they smelled an odor, and 1 reported not smelling an odor. Of the 10 symptomatic first responders, 6 reported ENT symptoms, 4 reported neurologic symptoms, 3 reported ophthalmic symptoms, and 5 reported cardiopulmonary symptoms (Table 4). Furthermore, 1 of the 10 symptomatic first responders sought care in an ED, urgent care, or outpatient clinic; 2 first responders self-treated; and the remaining 28 did not need healthcare. Discussion Nearly one half of the general health survey respondents reported a new or worsening symptom within the 2 weeks prior to survey completion. Moreover, reported contact with smoke, dust, or debris or report of smelling an odor was strongly associated with being symptomatic. This association suggests that the increase in reported symptoms could be related to reported exposure to the fire and its resulting material. Reported symptoms are consistent with previous reports of exposure to elevated PM2.5 and PM10 (An Han et al., 2020; Bazyar et al., 2019). While the long-term health e‹ects of this incident are unknown, other reports have identified adverse health outcomes reported many years after acute exposure to a chemical fire (Degher & Harding, 2004; Granslo et al., 2017; Greven et al., 2009). Given the high level of reported symptom burden in this sample, support for the community’s access to appropriate healthcare resources and ongoing monitoring for changes in health, such as via syndromic surveillance, should be prioritized. Findings from this investigation can also inform leaders to prepare for future emergency responses. Industrial companies can consider discussions to prevent and mitigate incidents with chemical exposures by having safety measures and emergency response resources to limit impact on the surrounding population and environment. Robust participation in Local Emergency Planning Committees can contribute to emergency response planning (U.S. EPA, 2022b). Careful attention to first responders’ working conditions and PPE, especially during chemical exposures, is important in protecting the health of this group (Melnikova et al., 2018). More attention to gender, racial, and ethnic minority groups and residents from areas with higher social vulnerability—who might be at higher risk for negative e‹ects from disasters—could contribute to a better understanding of if and how specific groups are disproportionately First Responders Reporting a New or Worsening Symptom Within the 2 Weeks Prior to Survey Completion, Winnebago County, Illinois, July 2021 Symptom Symptom Category First Responders Reporting (N = 31) # (%) Headache Neurological 4 (12.9) Irritation, pain, or burning in eyes Ophthalmic 3 (9.7) Coughing Cardiopulmonary 3 (9.7) Hoarseness ENT 2 (6.5) Stuffy nose or sinus congestion ENT 2 (6.5) Increased congestion or phlegm (mucus) ENT 2 (6.5) Asthma Cardiopulmonary 2 (6.5) Runny nose ENT 1 (3.2) Burning nose or throat ENT 1 (3.2) Odor on breath ENT 1 (3.2) Sensation in throat ENT 1 (3.2) Dizziness or lightheadedness Neurological 1 (3.2) Blurred or double vision Ophthalmic 1 (3.2) Difficulty breathing or feeling out-of-breath Cardiopulmonary 1 (3.2) Wheezing in chest Cardiopulmonary 1 (3.2) Note. Data include respondents of the first responders health survey and respondents of the general health survey who self-identified as first responders. Data exclude respondents of the general health survey who did not self-identify as first responders. Respondents were able to report more than one symptom. ENT = ears, nose, and throat. TABLE 4

14 Volume 85 • Number 7 V N N # # SCIENCE a ected by chemical exposures. Additionally, future investigations and survey methods (e.g., oversampling) could be beneficial in addressing this issue. Our findings are subject to limitations of the survey that was rapidly modified from an in-person, interviewer-administrated survey to an electronic, self-administrated survey with limited time for validation. The general health survey might not be representative of the entire exposed cohort because it used a convenience sample. Further, the general health survey was primarily accessed through a direct link emailed to registrants who signed up for COVID-19 vaccine updates and required respondents to provide contact information and demographic information. This sampled population might be more comfortable with electronic communications, interested in public health activities, and agreeable to providing identifying information in surveys than the general public (Tripepi et al., 2010). The general health survey used an adapted Epi CASE survey—a brief survey designed to capture information soon after a disaster—but it did not capture detailed information on behaviors that might have increased or decreased exposure, factors a ecting health status, or the nature of contact with material. Moreover, the general health survey did not collect detailed information, such as duration or intensity, about the characteristics of symptoms. Furthermore, the survey question about use of healthcare did not provide an option for respondents to indicate that they needed healthcare but lacked access, which could potentially mask the needs and experiences of di erent groups of people. Additionally, the 1-mi evacuation order and 3-mi masking advisory might have a ected respondents’ exposure, perception of risks, and responses to survey questions. Conclusion An epidemiological assessment was performed after a large chemical fire at a facility to identify potentially a ected areas and assess the health e ects of the fire in nearby communities and among first responders. This investigation was successful in using several public health tools after a fire at an industrial chemical facility in Winnebago County, Illinois. High levels of reported symptom burden were identified among surveyed residents. There were associations between respondents’ reported contact with material or report of smelling an odor with any reported new or worsening symptom. Results from this investigation might assist the directing of public health resources to e ectively address immediate community needs and prepare for future incidents. Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the o“cial position of CDC or ATSDR. Corresponding Author: Jasmine Y. Nakayama, Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop S107-5, Chamblee, GA 30341. Email: qdt2@cdc.gov. Agency for Toxic Substances and Disease Registry. (2014). ACE ToolKit. https://www.atsdr.cdc.gov/ntsip/ace_toolkit.html Agency for Toxic Substances and Disease Registry. (2016). Assessment of Chemical Exposures (ACE) Program. https://www.atsdr.cdc. gov/ntsip/ACE_ToolKit/docs/ACE_Fact%20Sheet_053014.pdf Agency for Toxic Substances and Disease Registry. (2020). Epi CASE Toolkit. https://www.atsdr.cdc.gov/epitoolkit/index.html Agency for Toxic Substances and Disease Registry. (2022). CDC/ ATSDR Social Vulnerability Index. https://www.atsdr.cdc.gov/place andhealth/svi/index.html An Han, H., Han, I., McCurdy, S., Whitworth, K., Delclos, G., Rammah, A., & Symanski, E. (2020). The Intercontinental Terminals Chemical Fire Study: A rapid response to an industrial disaster to address resident concerns in Deer Park, Texas. International Journal of Environmental Research and Public Health, 17(3), Article 986. https://doi.org/10.3390/ijerph17030986 Bazyar, J., Pourvakhshoori, N., Khankeh, H., Farrokhi, M., Delshad, V., & Rajabi, E. (2019). A comprehensive evaluation of the association between ambient air pollution and adverse health outcomes of major organ systems: A systematic review with a worldwide approach. Environmental Science and Pollution Research, 26(13), 12648–12661. https://doi.org/10.1007/s11356-019-04874-z Burkom, H., Loschen, W., Wojcik, R., Holtry, R., Punjabi, M., Siwek, M., & Lewis, S. (2021). Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE): Overview, components, and public health applications. JMIR Public Health and Surveillance, 7(6), e26303. https:// doi.org/10.2196/26303 Centers for Disease Control and Prevention. (2022). National Syndromic Surveillance Program (NSSP). https://www.cdc.gov/nssp/ index.html Degher, A., & Harding, A.K. (2004). Case study of a chemical fire in an urban neighborhood: A wakeup call for the emergency response system. Journal of Emergency Management, 2(3), 33–42. https://doi.org/10.5055/jem.2004.0031 Duncan, M.A. (2014). Assessment of chemical exposures: Epidemiologic investigations after large-scale chemical releases. Journal of Environmental Health, 77(2), 36–38. Duncan, M.A., & Orr, M.F. (2016). Toolkit for epidemiologic response to an acute chemical release. Disaster Medicine and Public Health Preparedness, 10(4), 631–632. https://doi.org/10.1017/ dmp.2015.187 Granslo, J.T., Bråtveit, M., Hollund, B.E., Lygre, S.H., Svanes, C., & Moen, B.E. (2017). A follow-up study of airway symptoms and lung function among residents and workers 5.5 years after an oil tank explosion. BMC Pulmonary Medicine, 17(1), Article 18. https://doi.org/10.1186/s12890-016-0357-3 References

March 2023 • Journal of Environmental Health 15 Greven, F., Kerstjens, H.A.M., Duijm, F., Eppinga, P., de Meer, G., & Heederik, D. (2009). Respiratory eects in the aftermath of a major fire in a chemical waste depot. Scandinavian Journal of Work, Environment & Health, 35(5), 368–375. https://doi.org/10.5271/sjweh.1328 Illinois Environmental Protection Agency. (2022). Chemtool Inc. https://www2.illinois.gov/epa/topics/community-relations/sites/ Chemtool/Pages/default.aspx Melnikova, N., Wu, J., Yang, A., & Orr, M. (2018). Acute chemical incidents with injured first responders, 2002–2012. Disaster Medicine and Public Health Preparedness, 12(2), 211–221. https:// doi.org/10.1017/dmp.2017.50 Surasi, K., Nakayama, J.Y., Johnson, M., Martell, S., Patrick, S., Owen, L.R., Horton, D.K., & Orr, M. (2021). Notes from the field: Deployment of an electronic self-administered survey to assess human health eects of an industrial chemical facility fire—Winnebago County, Illinois, June–July 2021. Morbidity and Mortality Weekly Report, 70(49), 1715–1716. https://doi.org/10.15585/ mmwr.mm7049a4 Tripepi, G., Jager, K.J., Dekker, F.W., & Zoccali, C. (2010). Selection bias and information bias in clinical research. Nephron Clinical Practice, 115(2), c94–c99. https://doi.org/10.1159/000312871 U.S. Census Bureau. (2021). American Community Survey 5-Year Data 2019. https://www.census.gov/data/developers/data-sets/acs5year/2019.html U.S. Census Bureau. (n.d.). Census—Geography profile. Winnebago County, Illinois. https://data.census.gov/cedsci/profile?g=0500000 US17201 U.S. Environmental Protection Agency. (2022a). Superfund site: BELOIT CORP., Rockton, IL. https://cumulis.epa.gov/supercpad/ cursites/csitinfo.cfm?id=0500272 U.S. Environmental Protection Agency. (2022b). Local Emergency Planning Committees. https://www.epa.gov/epcra/local-emergency- planning-committees U.S. Environmental Protection Agency. (n.d.). Chemtool fire. https:// response.epa.gov/site/site_profile.aspx?site_id=15241 World Health Organization and Environmental Health Team. (2006). WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide: Global update 2005: Summary of risk assessment. https://apps.who.int/iris/handle/ 10665/69477 References Join our environmental health community. It is the only community of people who truly understand what it means to do what you do every day to protect the health of our communities. Join us today. Your people are waiting. neha.org/membership Find Your People. Find Your Training. Find Your Resources.

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