The Association of Stair Climbing Behaviors With Hazard of All-Cause Mortality in Adults With or At Risk of Knee Osteoarthritis

OBJECTIVE

To investigate the association of stair climbing difficulty and stair climbing frequency with the risk of all-cause mortality over 13 years in adults with or at high risk for knee OA.

METHODS

We used data from the Osteoarthritis Initiative (OAI), a prospective cohort study of community-dwelling adults with or at high risk for symptomatic knee OA. The exposures were stair climbing difficulty and frequency, assessed at baseline using self-report questionnaires. The outcome was all-cause mortality, assessed from baseline through 13 years of follow-up. Kaplan-Meier survival curves and Cox proportional hazards regression were used to investigate the association between stair climbing exposures and all-cause mortality.

RESULTS

Three hundred seven (6.81%) and 310 (6.84%) participants in the difficulty and frequency samples, respectively, died during 13 years of follow-up. Those who were limited in any capacity in terms of their stair climbing ability had 54% to 84% greater hazard of all-cause mortality, and those who climbed at least 7 flights of stairs per week had 38% lower hazard of all-cause mortality.

CONCLUSION

Adults with or at high risk for knee OA who report difficulty with climbing stairs or who infrequently use stairs are at greater hazard of all-cause mortality. Stair climbing difficulty and frequency are simple to collect and changes may occur early in OA progression, allowing for early intervention. Brief questions about stair climbing behaviors can serve as a functional vital sign within the clinician's toolbox.

Impacts of the COVID-19 Response on the Domestic Violence Workforce

Many frontline and essential workers faced increased levels of stress, anxiety, depression, and even suicide ideation during the pandemic response. These and other factors led to burnout, shifts into non-patient or client-facing roles, or leaving an occupation altogether. Domestic violence advocates experienced increases in many types of stressors as they continued to provide essential services to victims and survivors during the pandemic. However, in most cases they did so without protections offered to essential workers, like priority access to personal protective equipment (PPE) or vaccines. Executive directors of U.S. State and Territorial Domestic Violence Coalitions were identified using the National Network to End Domestic Violence website and contacted via email to schedule key informant interviews. Interviews were conducted, recorded, and transcribed using Zoom. Themes were identified using both inductive and deductive coding. Twenty-five of 56 (45%) coalition executive directors completed an interview. Three main themes related to workforce were identified, including an accelerated rate of job turnover among both leadership and staff; a lack of essential worker status for domestic violence advocates; and unsustainable levels of stress, fear, and exhaustion. While familiar challenges drove these outcomes for this predominantly female, low-wage workforce, such as a lack of access to childcare, other factors, including the lack of access to PPE, training, and hazard pay for those working in person, highlighted inequities facing the domestic violence workforce. The factors identified as impacting the domestic violence workforce-turnover, low status, and high levels of stress, fear, and exhaustion-made the already challenging provision of advocacy and services more difficult. Domestic violence advocates are essential first responders and must be supported in ways that increase the resilience of empowerment-based services for victims and survivors.

How Interprofessional Community Mobile Healthcare and Service-Learning Work Together to Identify and Address Chronic Health Disparities

Background

Residents of the State of Delaware experience high levels of health inequities. Service-learning programs provided jointly by universities and community partners can address health disparities through documentation of disparities and service provision that sees patients where they are. Benefits accrue for both students and communities experiencing health inequities.

Methods

HEALTH for All (H4A) mobile unit clients can receive a variety of services at sites co-located with community based organizations (CBOs). Between September 2023 and January 2024, H4A clients had their blood pressure assessed by a trained healthcare provider. Demographic and ZIP Code of residence data were collected by a trained graduate student. Data were recorded and analyzed using Microsoft Excel Version 16.5 (Redmond, WA, USA). All documentation was reviewed and approved by the University of Delaware's Institutional Review Board (IRB #1567044-3).

Results

Between September 2023 and January 2024, 152 clients participated. Most participants were female (72.27%; 104 of 143) and identified as White (68.66%; 92 of 134). The largest group of clients were in Stage 1 Hypertension (34.21%; 52 of 152), followed by Elevated (23.68%; 36 of 152), Normal (22.37%; 34 of 152), and Stage 2 Hypertension (19.74%; 30 of 152). Black or African American clients had higher systolic and diastolic blood pressure compared to other racial and ethnic groups. There were also differences in the share of clients with hypertension by ZIP Code of residence.

Conclusions

Interprofessional service-learning in a mobile health context provides students with practical field experience and real-world insights into community perspectives and needs, including addressing health inequities. Academic-community partnerships and mobile health programs should be prioritized in the future to address health inequities and foster the development of socially engaged, community-minded future professionals.

Chickenpox Outbreaks in Three Refugee Camps on Mainland Greece, 2016-2017: A Retrospective Study

INTRODUCTION

Displaced populations face disproportionately high risk of communicable disease outbreaks given the strains of travel, health care circumstances in their country of origin, and limited access to health care in receiving countries.

STUDY OBJECTIVE

Understanding the role of demographic characteristics in outbreaks is important for timely and efficient control measures. Accordingly, this study assesses chickenpox outbreaks in three large refugee camps on mainland Greece from 2016 - 2017, using clinical line-list data from Médecins du Monde (MdM) clinics.

METHODS

Clinical line-list data from MdM clinics operating in Elliniko, Malakasa, and Raidestos camps in mainland Greece were used to characterize chickenpox outbreaks in these camps. Logistic regression was used to compare the odds of chickenpox by sex, camp, and yearly increase in age. Incidences were calculated for age categories and for sex for each camp outbreak.

RESULTS

Across camps, the median age was 19 years (IQR: 7.00 - 30.00 years) for all individuals and five years (IQR: 2.00 - 8.00 years) for cases. Males were 55.94% of the total population and 51.32% of all cases. There were four outbreaks of chickenpox across Elliniko (n = 1), Malakasa (n = 2), and Raidestos (n = 1) camps. The odds of chickenpox when controlling for age and sex was lower for Malakasa (OR = 0.46; 95% CI, 0.38 - 0.78) and Raidestos (OR = 0.36; 95% CI, 0.24 - 0.56) when compared Elliniko. Odds of chickenpox were comparable between Malakasa and Raidestos (OR = 1.49; 95% CI, 0.92 - 2.42). Across all camps, the highest incidence was among children zero-to-five years of age. The sex-specific incidence chickenpox was higher for males than females in Elliniko and Malakasa, while the incidence was higher among females in Raidestos.

CONCLUSION

As expected, individuals five years of age and under made up the majority of chickenpox cases. However, 12% of cases were teenagers or older, highlighting the need to consider atypical age groups in vaccination strategies and control measures. To support both host and displaced populations, it is important to consider risk-reduction needs for both groups. Including host communities in vaccination campaigns and activities can help reduce the population burden of disease for both communities.

Lessons Learned From the COVID-19 Pandemic in the United States by Domestic Violence Coalition Leaders

This U.S. study explores lessons learned about domestic violence service delivery during the COVID-19 pandemic identified by state, territory, and tribal coalition leadership to advance preparedness and guide structural improvements for future disasters. Semi-structured interviews with 25 Coalition leaders identified public health control measures and victim-centered strategies used to mitigate the pandemic's impacts on services and advocacy. Three main themes emerged: workforce innovations, system empowerment, and the simultaneous pandemic of racial injustice. The COVID-19 pandemic inspired Coalitions to respond creatively and highlighted resources needed to support survivors and the domestic violence (DV) workforce going forward, including reassessing the current state of the DV movement.

Threats to public health workers

Media reports and data from public health professional membership organizations have demonstrated high levels of harassment experienced by public health workers throughout the COVID-19 response. We documented personal and political threats to public health workers across the first 12 months of pandemic response through a longitudinal survey completed in Fall 2020 and Summer 2021. The web-based survey was distributed to respondents using the Qualtrics survey platform. Survey items measured domains including demographic information, public health roles and training, mental and physical health, and work-life balance. Respondents were also asked if they had received any personal or political threats, from whom these threats were received, and completed an open-ended question describing the nature of the threats. Among the 85 public health workers completing both surveys, threats from members of the public and from elected and appointed leaders were most prevalent at both timepoints; however, as the pandemic response progressed, the nature of threats to public health workers changed. While those remaining in the public health workforce may be more resilient to these threats, increased prevalence of personal and political threats has the potential to deter new graduates from entering the field, impacting the public health system's future response capacity.

Changes in anxiety and depression among public health workers during the COVID-19 pandemic response

OBJECTIVES

The COVID-19 pandemic has negatively impacted mental health indicators, leading to an increase in symptoms of anxiety and depression in both the general population of adults and children and many occupational groups. This study aims to examine changes in anxiety and depression among a cohort of public health workers in the U.S. during the first year of the COVID-19 pandemic and identify potential risk factors.

METHODS

Longitudinal data were collected from a sub-sample (N = 85) of public health workers in 23 U.S. states who completed two surveys in 2020 and 2021. Information on background characteristics, personal well-being, and work environment as well as validated scales to assess generalized anxiety disorder (GAD), depressive disorder, and burnout was collected. Data were analyzed using Stata Version 17, and significant differences were determined using Pearson's Chi2 and Fisher's Exact tests.

RESULTS

The proportion of those reporting GAD (46.3% to 23.2%) or depression (37.8% to 26.8%) improved from Survey 1 to Survey 2 overall; symptoms of anxiety saw the largest improvement. Persistent depression was associated with sustained burnout, changes in social support, and days worked per week.

CONCLUSION

Public health workers experienced elevated levels of anxiety and depression during the initial pandemic response, but a reduction in these symptoms was observed in the subsequent year after vaccines had become widely available. However, unmet needs remain for ongoing workplace mental health supports to address burnout, as well as for additional emotional supports outside of work for public health professionals.

Characterizing the impacts of public health control measures on domestic violence services: qualitative interviews with domestic violence coalition leaders

BACKGROUND

Prior to the availability of pharmaceutical control measures, non-pharmaceutical control measures, including travel restrictions, physical distancing, isolation and quarantine, closure of schools and workplaces, and the use of personal protective equipment were the only tools available to public health authorities to control the spread of COVID-19. The implementation of these non-pharmaceutical control measures had unintended impacts on the ability of state and territorial domestic violence coalitions to provide services to victims.

METHODS

A semi-structured interview guide to assess how the COVID-19 pandemic impacted service provision and advocacy generally, and how COVID-19 control measures specifically, created barriers to services and advocacy, was developed, pilot tested, and revised based on feedback. Interviews with state and territorial domestic violence coalition executive directors were conducted between November 2021 and March 2022. Transcripts were inductively and deductively coded using both hand-coding and qualitative software.

RESULTS

Forty-five percent (25 of 56) of state and territorial domestic violence coalition executive directors representing all 8 National Network to End Domestic Violence (NNEDV) regions were interviewed. Five themes related to the use of non-pharmaceutical pandemic control measures with impacts on the provision of services and advocacy were identified.

CONCLUSIONS

The use of non-pharmaceutical control measures early in the COVID-19 pandemic had negative impacts on the health and safety of some vulnerable groups, including domestic violence victims. Organizations that provide services and advocacy to victims faced many unique challenges in carrying out their missions while adhering to required public health control measures. Policy and preparedness plan changes are needed to prevent unintended consequences of control measure implementation among vulnerable groups as well as to identify lessons learned that should be applied in future disasters and emergencies.

Disease burden among refugees in camps on mainland Greece, 2016-2017: a retrospective cross-sectional study

BACKGROUND

Despite the importance of baseline health data for evidence-informed decision-making, these data are rarely available for displaced populations. At the height of the European refugee crisis, most of those seeking asylum in Europe were from regions with high prevalences of communicable and non-communicable diseases. To create an epidemiologic profile for refugees in camps on mainland Greece, this study assessed the prevalence of 11 communicable and non-communicable diseases among refugees utilizing Médecins du Monde (MdM) in-camp clinics.

METHODS

The proportional morbidity of selected diseases among individuals utilizing MdM services were determined from data collected at refugee camp clinics on mainland Greece from April 2016 - July 2017. Overall and age-specific proportional morbidities were reported. Differences in disease burden among refugees from the largest sending countries - Afghanistan and Syria - were compared using proportional morbidity ratios and 95% confidence intervals. Patterns in results were compared with disease burden estimates in sending countries and with findings from comparable settings.

RESULTS

Respiratory tract infections (RTIs) were the most prevalent outcome. Among RTIs, upper RTIs were most common, with a proportional morbidity of nearly 40%; throughout the study period, over 46% of children under 18 years had at least one upper RTI consultation. Musculoskeletal conditions (3.64%), were the most prevalent non-communicable outcome, followed by hypertension (2.21%) and asthma (1.28%). Afghans were 31.68% more likely than Syrians to have a consultation for at least one condition (PR: 1.32; 95% CI: 1.25, 1.39). The proportional morbidity of RTIs was comparable to sending countries, but there was a comparatively lower burden of other conditions among refugees than literature estimates from sending countries.

CONCLUSION

Refugees utilizing MdM clinics in camps had higher burdens of communicable diseases - predominantly RTIs - relative to non-communicable diseases. Non-communicable disease burdens were comparatively lower than reported prevalences from in-country populations. These findings can be attributed to a range of considerations including differences in demographic profiles between sending countries and refugee populations and missed opportunities for utilizing clinical care. Further investment is needed to capture the health profiles of displaced populations to support evidence-informed decision-making processes in humanitarian emergency responses.

Health Research in the Wake of Disasters: Challenges and Opportunities for Sensor Science

BACKGROUND

Disaster events adversely affect the health of millions of individuals each year. They create exposure to physical, chemical, biological, and psychosocial hazards while simultaneously exploiting community and individual-level vulnerabilities that allow such exposures to exert harm. Since 2013, the National Institute of Environmental Health Sciences (NIEHS) has led the development of the Disaster Research Response (DR2) program and infrastructure; however, research exploring the nature and effects of disasters on human health is lacking. One reason for this research gap is the challenge of developing and deploying cost-effective sensors for exposure assessment during disaster events.

OBJECTIVES

The objective of this commentary is to synergize the consensus findings and recommendations from a panel of experts on sensor science in support of DR2.

METHODS

The NIEHS convened the workshop, "Getting Smart about Sensors for Disaster Response Research" on 28 and 29 July 2021 to discuss current gaps and recommendations for moving the field forward. The workshop invited full discussion from multiple viewpoints, with the goal of identifying recommendations and opportunities for further development of this area of research. The panel of experts included leaders in engineering, epidemiology, social and physical sciences, and community engagement, many of whom had firsthand experience with DR2.

DISCUSSION

The primary finding of this workshop is that exposure science in support of DR2 is severely lacking. We highlight unique barriers to DR2, such as the need for time-sensitive exposure data, the chaos and logistical challenges that ensue from a disaster event, and the lack of a robust market for sensor technologies in support of environmental health science. We highlight a need for sensor technologies that are more scalable, reliable, and versatile than those currently available to the research community. We also recommend that the environmental health community renew efforts in support of DR2 facilitation, collaboration, and preparedness. https://doi.org/10.1289/EHP12270.

Ensuring Access to Opioid Treatment Program Services Among Delawareans Vulnerable to Flooding

Objective

To quantify potential flood-related access disruptions to medication-assisted treatment for opioid use disorder (OUD) among Delawareans.

Methods

Spatial flood risk maps and infrastructure, services, and hazard risk, transportation networks, opioid treatment programs (OTPs) for the State of Delaware were integrated to visually display the relationship between these layers. A complex network theory-based simulation model was used to assess both direct (e.g., inundation with flood water) and indirect (e.g., isolation) impacts of floods.

Results

Delaware is at increasing risk from flooding associated with storms and sea-level rise, which can lead to sunny day flooding during high tides. Of the 18 OTPs in Delaware, 4 are expected to be flooded in a 100-year flood and 7 are expected to be severely disrupted, increasing to 9 by 2035 and to 10 by 2050, with service reachability less than 15 square miles due to flood-induced isolation.

Conclusions

Individuals utilizing OTPs for OUDs must be able to access treatment programs regardless of external disruptors like floods. Because these programs require consistent treatment adherence and in-person oversight by clinicians, timely restoration of services and continuity of operations for treatment facilities in post-disaster settings is critical for treatment compliance.

Policy Implications

The State of Delaware has the third highest rate of drug overdose mortality in the U.S., with three-quarters of all drug-related deaths involving opioids. Impeded access to opioid treatment during a flood disaster can lead to relapse, overdose, and death. Hazard planning must develop policies and practices to address these risks.

Calculating the Environmental Impacts of Low-Impact Development Using Long-Term Hydrologic Impact Assessment: A Review of Model Applications

Low-impact development (LID) is a planning and design strategy that addresses water quality and quantity while providing co-benefits in the urban and suburban landscape. The Long-Term Hydrologic Impact Assessment (L-THIA) model estimates runoff and pollutant loadings using simple inputs of land use, soil type, and climatic data for the watershed-scale analysis of average annual runoff based on curve number analysis. Using Scopus, Web of Science, and Google Scholar, we screened 303 articles that included the search term "L-THIA", identifying 47 where L-THIA was used as the primary research method. After review, articles were categorized on the basis of the primary purpose of the use of L-THIA, including site screening, future scenarios and long-term impacts, site planning and design, economic impacts, model verification and calibration, and broader applications including policy development or flood mitigation. A growing body of research documents the use of L-THIA models across landscapes in applications such as the simulations of pollutant loadings for land use change scenarios and the evaluation of designs and cost-effectiveness. While the existing literature demonstrates that L-THIA models are a useful tool, future directions should include more innovative applications such as intentional community engagement and a focus on equity, climate change impacts, and the return on investment and performance of LID practices to address gaps in knowledge.

Online Guidance for Domestic Violence Survivors and Service Providers: A COVID-19 Content Analysis

To assess COVID-19 information and services available to domestic violence service providers, survivors, and racially and culturally specific communities in the U.S., a content analysis of 80 national and state/territorial coalition websites was performed in June 2020. COVID-19 information was available on 84% of websites. National organizations provided more information for survivors related to safety and mental health and for racially and culturally specific communities. State/territorial coalitions provided more information for providers on COVID-19 and general disaster preparedness. COVID-19 and social distancing measures implemented to control it diminished help-seeking in unique ways. Greater online access to information and resources may be needed to address changing needs of survivors during disasters and emergencies.

Determinants of Under-Five Mortality in an Armed Conflict Setting: Empirical Findings from the Demographic and Health Surveys

Insurgencies like Boko Haram may impact the physical health and well-being of adults and children living in geographic areas under their political control. However, it is difficult to obtain reliable health data in conflict-affected areas. This study explored the potential to use data from the Demographic and Health Surveys (DHS) to examine the determinants of under-five mortality in Northern Nigeria. Data were derived from DHS conducted before and after the start of the Boko Haram insurgency in 2009. A multi-level mixed effects logistic regression model was used to identify predictors of under-five mortality in an armed conflict setting. Results were reported as adjusted odds ratios (aOR) and 95% confidence intervals (CI). Residence in an armed conflict setting was not significantly associated with under-five mortality (aOR = 1.06; 95% CI: 1.00, 1.10). However, twin gestation (aOR = 3.18; 95% CI:2.96, 3.42), wealth index of family (richest versus poorest: aOR = 0.42; 95% CI: 0.37, 0.47), religion of mother (Islam versus Christianity: aOR = 1.50; 95% CI: 1.43, 1.57); highest educational level of mother (higher versus none: aOR = 0.33; 95% CI: 0.29, 0.37), and parity of mother, significantly predicted death before the fifth birthday. Repeated studies are needed to assess the impact of Boko Haram insurgency on physical health outcomes, particularly in areas where primary data collection is difficult or impossible.

Lessons Learned From the Public Health Workforce's Experiences With the COVID-19 Response

Limited research is available on the COVID-19 response experiences of local, state, and federal public health workers in the United States. Although the response to COVID-19 is still presenting challenges to the public health workforce, public health systems must also begin to consider lessons learned that can be applied to future disasters. During July and August 2021, a random sample of participants from a cross-sectional study of the public health workforce was invited to participate in interviews to obtain information on the current state of public health operations, the ongoing response to the COVID-19 crisis, and takeaways for improving future preparedness and response planning. Interviews were transcribed and inductively coded to identify themes. Twenty-four initial interview invitations were sent, and random substitutions were made until thematic saturation was reached when 17 interviews were completed. Four thematic categories were identified, including challenges related to (1) ongoing lack of political support or policy guidance; (2) fluctuations in, and uncertainty about, future funding and associated requirements; (3) job expectations, including remote work and data-sharing capabilities; and (4) the mental health toll of sustained response and related burnout. As the public health response to the COVID-19 pandemic continues in its third year, it is crucial to identify lessons learned that can inform future investment in order to sustain a public health workforce and a public health preparedness and response system that is resilient to future disasters.

Surveys of community garden affiliates and soils in Houston, Texas

Although urban community food gardens have the capacity to strengthen and support neighborhoods in need, the benefits of such operations must be considered in tandem with the potential risks associated with urban environmental contamination. Therefore, research is needed to characterize existing community gardens in urban areas. In the present study, a survey of Houston, TX, community gardeners (N = 20) was conducted to better understand their risk-based knowledge and perceptions, current gardening practices, and willingness to implement risk mitigation measures. Soil samples collected from the beds (N = 22) and surrounding grounds (N = 24) of existing community garden sites in Houston, TX, were screened for trace and heavy metals using X-ray fluorescence spectrometry. The survey indicated that community gardeners had few concerns with regard to potential soilborne hazards and were generally willing to use diverse strategies to reduce potential hazards related to garden soil contamination. Ground and garden bed soil collected from community gardens were found to have excess concentrations of arsenic compared to federal health screening limits. The information provided here provides insight into possible discordance between community gardening risk perception and contamination risk that could be addressed through outreach, engagement, and remediation approaches.

Healthcare provider and medical student impressions of vaccine hesitancy in Romania

Objectives

Study design

Methods

Results

Conclusion

Biosensor applications in contaminated estuaries: Implications for disaster research response

BACKGROUND

Given the time and monetary costs associated with traditional analytical chemistry, there remains a need to rapidly characterize environmental samples for priority analysis, especially within disaster research response (DR2). As PAHs are both ubiquitous and occur as complex mixtures at many National Priority List sites, these compounds are of interest for post-disaster exposures.

OBJECTIVE

This study tests the field application of the KinExA Inline Biosensor in Galveston Bay and the Houston Ship Channel (GB/HSC) and in the Elizabeth River, characterizing the PAH profiles of these region's soils and sediments. To our knowledge, this is the first application of the biosensor to include soils.

METHODS

The biosensor enables calculation of total free PAHs in porewater (C free), which is confirmed through gas chromatography-mass spectrometry (GC-MS) analysis. To determine potential risk of the collected soils the United States Environmental Protection (USEPA) Agency's Regional Screening Level (RSL) Calculator is used along with the USEPA Region 4 Ecological Screening Values (R4-ESV) and Refined Screening Values (R4-RSV).

RESULTS

Based on GC-MS results, all samples had PAH-related hazard indices below 1, indicating low noncarcinogenic risks, but some samples exceeded screening levels for PAH-associated cancer risks. Combining biosensor-based C free with Total Organic Carbon yields predictions highly correlated (r > 0.5) both with total PAH concentrations as well as with hazard indices and cancer risks. Additionally, several individual parent PAH concentrations in both the GB/HSC and Elizabeth River sediments exceeded the R4- ESV and R4-RSV values, indicating a need for follow-up sediment studies.

CONCLUSIONS

The resulting data support the utility of the biosensor for future DR2 efforts to characterize PAH contamination, enabling preliminary PAH exposure risk screening to aid in prioritization of environmental sample analysis.

Resident perspectives of environmental health risk exposures after Hurricane Harvey

This study examines what visitors to urban parks in Houston, TX, know about environmental health risks resulting from Hurricane Harvey, a category 4 storm that made landfall in August 2017 and dropped over 60 in. of rain in 8 days making it the most significant rainfall event in US history. Interviews were conducted with adult Houstonians using purposive sampling. In total, 27 interviews were conducted with 36 different participants. Interviews were audio-recorded, transcribed verbatim, and analyzed qualitatively using a phronetic iterative approach. This study found that park visitors lack sufficient knowledge about environmental health risks, yet they have strong desires to learn more about such risks. In particular, participants have clear opinions on what the content of the messages (i.e., concise, manageable, not fear-inducing) should be and how they would like to receive the information (i.e., conveniently accessible, from trusted local sources). Implications for health campaign interventions utilizing uncertainty theories are discussed.

Increased prevalence of indoor Aspergillus and Penicillium species is associated with indoor flooding and coastal proximity: a case study of 28 moldy buildings

Indoor flooding is a leading contributor to indoor dampness and the associated mold infestations in the coastal United States. Whether the prevalent mold genera that infest the coastal flood-prone buildings are different from those not flood-prone is unknown. In the current case study of 28 mold-infested buildings across the U.S. east coast, we surprisingly noted a trend of higher prevalence of indoor Aspergillus and Penicillium genera (denoted here as Asp-Pen) in buildings with previous flooding history. Hence, we sought to determine the possibility of a potential statistically significant association between indoor Asp-Pen prevalence and three building-related variables: (i) indoor flooding history, (ii) geographical location, and (iii) the building's use (residential versus non-residential). Culturable spores and hyphal fragments in indoor air were collected using the settle-plate method, and corresponding genera were confirmed using phylogenetic analysis of their ITS sequence (the fungal barcode). Analysis of variance (ANOVA) using Generalized linear model procedure (GLM) showed that Asp-Pen prevalence is significantly associated with indoor flooding as well as coastal proximity. To address the small sample size, a multivariate decision tree analysis was conducted, which ranked indoor flooding history as the strongest determinant of Asp-Pen prevalence, followed by geographical location and the building's use.

A Qualitative Study of the COVID-19 Response Experiences of Public Health Workers in the United States

The mental health impacts of the COVID-19 pandemic on frontline, patient-facing healthcare staff have been described in several studies, but the effects of the COVID-19 response on the US public health workforce have not been well characterized. In early 2021, we conducted interviews with a subset of public health practitioners in the United States who participated in a cross-sectional survey and indicated their willingness to participate in a follow-up interview. An interview guide was developed to collect information about professional roles since the start of the pandemic, aspects of the individual COVID-19 response that impacted mental health, and aspects of the organizational/institutional COVID-19 response that impacted mental health, as well as the strengths and weaknesses of, opportunities for, and threats to public health professionals and organizations going forward. Interviews were transcribed and inductively coded to identify themes. Of the 48 people invited to participate, 24 completed an interview between January 28 and February 23, 2021. Five key themes were identified through inductive coding of interview transcripts: (1) teamwork and workplace camaraderie, (2) potential for growth in the field of public health, (3) considerations for adaptive work environments (eg, remote work, work out of jurisdiction, transition to telework), (4) politicization of response, and (5) constrained hiring capacity and burnout. After more than a year of public health emergency response to the COVID-19 pandemic, it is critically important to understand the detrimental and supportive factors of good mental health among the public health workforce.

The impact of the COVID-19 response on the provision of other public health services in the U.S.: A cross sectional study

Introduction

Funding and staff formerly dedicated to routine public health tasks (e.g., responding to communicable and non-communicable diseases, investigating foodborne outbreaks, conducting routine surveillance) and services (e.g., environmental health, substance abuse, maternal-child health) may no longer be available in many public health departments due to the COVID-19 response. The objective of this study was to assess the extent to which staffing for essential public health services has been redirected to the COVID-19 response.

Materials and methods

This is a cross-sectional study using a survey distributed through the Qualtrics platform. Individuals (N = 298) working in public health across governmental and academic public health departments in the U.S. during the ongoing COVID-19 pandemic response were surveyed. Survey items measured multiple domains including professional experience (i.e., training, years of experience, content expertise, job functions, hours worked), mental and physical health status (i.e., generalized anxiety, depression, burnout), and career plans (i.e., pre-pandemic vs. current career plans).

Results

The total number of content expertise areas and programmatic functions covered by individual public health workers increased between January and September of 2020, with 26% (73 of 282) of respondents reporting an increase in both. The total number of respondents working in infectious disease and preparedness remained constant, while declines were reported in program evaluation (-36%) and health education (-27%) and increases were reported in disease investigation (+35%).

Conclusions

The provision of many essential public health functions and tasks have been limited or eliminated while the U.S. public health workforce responds to the COVID-19 pandemic. These findings highlight opportunities for funding and professional development of public health systems, both during and after the COVID-19 response, to help ensure the continuity of essential public health services, staffing sustainability, and preparedness for future public health emergencies in the U.S.

When Apologies become Meaningful: Perceptions of Apologies in Environmental Justice Communities

In the United States, people of color from low income and working-class backgrounds are at disproportionate risk to pollution and other environmental stressors. These environmental justice communities (EJCs) can also experience increased risk when a natural disaster collides with a preexisting environmental risk. The current research is an exploratory field study that examines perceptions of environmental risk after a natural disaster and how meaningful a public apology would be in three communities. Residents (N=161) in two EJCs and a community without documented risks reported their environmental concerns and perceptions of public apologies. Overall, EJC residents reported greater concern about chemical hazard exposure than did residents with decreased risk. Furthermore, chemical exposure concerns facilitated public apology meaningfulness within the EJCs, but not in the decreased risk community.

The Impact of Natural Disasters on Suicide in the United States, 2003–2015

Abstract. Background: Natural disasters are increasing in frequency and severity and impacted populations develop mental health conditions at higher rates than those not impacted. Aims: In this study, we investigate the association between exposure to a major natural disaster and suicide in the US. Method: Using county-level data on disaster declarations, mortality files, and population data, suicide rates were estimated for three 12-month periods before and after the disaster. Pooled rates were estimated predisaster and compared with postdisaster suicide rates using Poisson-generated Z tests and 95% confidence intervals. Results: A total of 281 major disasters were included. The suicide rate increased for each type of disaster and across all disasters in the first 2 years of follow-up. The largest overall increases in suicide rates were seen 2 years postdisaster. Limitations: Limitations include the ecologic study design, county-level exposure, and low power. Conclusion: Increases in county-level suicide rates after disasters were not statistically significant, although there was evidence that increases were delayed until 2 years postdisaster. Additional studies are needed to improve understanding of nonfatal suicide attempts after disasters and the role elevated social support plays in suicide prevention postdisaster. Future studies should consider pre-existing mental health, secondary stressors, and proximity to hazards.

Polycyclic Aromatic Hydrocarbons in Houston Parks After Hurricane Harvey

Unprecedented inland precipitation and catastrophic flooding associated with Hurricane Harvey potentially redistributed contaminants from industrial sites and transportation infrastructure to recreational areas that make up networks of green infrastructure, creeks, and waterways used for flood control throughout the Greater Houston Area. Sediment samples were collected in parks located near the Buffalo Bayou watershed 1 week after Hurricane Harvey made landfall and again 7 weeks later. Total concentrations of the U.S. Environmental Protection Agency's (EPA's) 16 priority polycyclic aromatic hydrocarbons (PAHs) were measured in each sample at both time points. Diagnostic ratios were calculated to improve understanding of potential sources of PAHs after flooding. Diagnostic ratios suggest vehicular traffic to be a potential source for PAHs in parks. Although the concentrations of PAHs in all samples were below EPA actionable levels, given that no background values were available for comparison, it is difficult to quantify the impact flooding from Hurricane Harvey had on PAH concentrations in Houston parks. However, given the high frequency of flooding in Houston, and the concentration of industrial facilities and transportation infrastructure adjacent to recreation areas, these data demonstrate that PAHs were still present after unprecedented flooding. This study may also serve as a baseline for future efforts to understand the environmental health impacts of disasters.

Addressing Challenges to Building Resilience Through Interdisciplinary Research and Engagement

Resilient communities are less affected by, and recover faster from, natural disasters. To be resilient in rapidly changing contemporary environments subject to the effects of complex factors such as climate change and urbanization, communities must effectively and efficiently adapt to new conditions to minimize future risks. To develop resilience, the hazards to which the community is exposed and vulnerable (i.e., future hurricanes, subsidence, salt water intrusion) must be accurately assessed, the systems (i.e., natural, built, and social) must be well understood, and the community must be engaged in the proactive planning and priority setting process. An approach to building resilience that utilizes the adaptive capacity of planning highlights opportunities to work collaboratively across disciplines to incorporate models and data from different disciplines to reduce uncertainty. We present one interdisciplinary group's approach to addressing challenges to building resilience through proactive planning, including: (1) characterizing hazards more accurately; (2) improving understanding of the vulnerability of natural (e.g., climate and infrastructure) systems subject to hazards; and (3) capturing potential synergies from interactions between planning and policies that govern decisions about the design of human settlements in hazardous areas.

Associations Between State Public Health Agency Structure and Pace and Extent of Implementation of Social Distancing Control Measures

OBJECTIVE

To assess associations between state public health agency governance and timing and extent of implementation of social distancing control measures during COVID-19 response.

DESIGN

State public health agencies were stratified by governance, and data on timing and extent of social distancing were collected from the Institute for Health Metrics and Evaluation. Multinomial logistic regression and time-to-event analyses were conducted to quantify impacts of governance structure on timing and extent of social distancing.

SETTING

State health departments in the United States.

RESULTS

States operating under centralized public health governance structures enacted social distancing 4 days after decentralized states and had a 73% reduced likelihood of enacting a social distancing policy (hazard ratio = 0.27; 95% CI, 0.08 to 0.86).

CONCLUSION

State health department governance structure may have implications on timing and extent of social distancing control measures implemented during a public health emergency.

Changes to Timeliness and Completeness of Infectious Disease Reporting in Texas After Implementation of an Epidemiologic Capacity Program

OBJECTIVES

The objective of this study was to characterize the changes in timeliness and completeness of disease case reporting in Texas in response to an increasing number of foodborne illnesses and high-consequence infectious disease investigations and the Texas Department of State Health Services' new state-funded epidemiologist (SFE) program.

METHODS

We extracted electronic disease case reporting data on 42 conditions from 2012 through 2016 in all local health department (LHD) jurisdictions. We analyzed data on median time for processing reports and percentage of complete reports across time and between SFE and non-SFE jurisdictions using Mann-Whitney t tests and z scores.

RESULTS

The median time of processing improved from 13 days to 10 days from 2012 to 2016, and the percentage of disease case reports that were complete improved from 19.6% to 27.7%. Most reports were for foodborne illnesses; both timeliness (11 to 7 days) and completeness (20.9% to 23.5%) improved for these reports.

CONCLUSIONS

Disease reporting improvements in timeliness and completeness were associated with the SFE program and its enhancement of epidemiologic capacity. SFEs were shown to improve surveillance metrics in LHDs, even in jurisdictions with a high volume of case reports. Adding epidemiologist positions in LHDs produces a tangible outcome of improved disease surveillance.

Spatial Distribution of Polycyclic Aromatic Hydrocarbon Contaminants after Hurricane Harvey in a Houston Neighborhood

BACKGROUND

Hurricane Harvey made landfall along the Texas Gulf Coast as a Category 4 hurricane on August 25, 2017, producing unprecedented precipitation that devastated coastal areas. Catastrophic flooding in the City of Houston inundated industrial and residential properties resulting in the displacement and transfer of soil, sediment, and debris and heightening existing environmental justice (EJ) concerns.

OBJECTIVES

The primary aim of this study was to evaluate the presence, distribution, and potential human health implications of polycyclic aromatic hydrocarbons (PAHs) in a residential neighborhood of Houston, Texas following a major hurricane.

METHODS

Concentrations of PAHs in 40 soil samples collected from a residential neighborhood in Houston, Texas were measured. Spatial interpolation was applied to determine the distribution of PAHs. Potential human health risks were evaluated by calculating toxicity equivalency quotients (TEQs) and incremental excess lifetime cancer risk (IELCR).

RESULTS

Total priority PAH concentrations varied across samples (range: 9.7 × 10¹ ng/g-1.6 × 10⁴ ng/g; mean: 3.0 × 10³ ng/g ± 3.6 × 10³ standard deviation). Spatial analysis indicated a variable distribution of PAH constituents and concentrations. The IELCR analysis indicated that nine of the 40 samples were above minimum standards.

CONCLUSIONS

Findings from this study highlight the need for fine scale soil testing in residential areas as well as the importance of site-specific risk assessment.

COMPETING INTERESTS

The authors declare no competing financial interests.

Advancing the Toxics Mobility Inventory: Development and Application of a Toxics Mobility Vulnerability Index to Harris County, Texas

Harris County, Texas, is home to thousands of documented sources of environmental pollution. It is also highly vulnerable to impacts from natural hazards, including floods. Building on the Toxics Mobility Inventory (TMI), this article discusses how the authors developed a Toxics Mobility Vulnerability Index (TMVI) and applied it to Harris County to assess potential exposure risks to residents from the transfer of toxic materials during flood events. The TMI concept was operationalized and standardized by combining multiple spatial data sets to simultaneously evaluate various factors in the weather hazards-extant toxics-social vulnerability nexus (e.g., floodplain area, industrial land use, social vulnerability measures). Findings indicated hot spots of vulnerability to hazard-induced toxics transfer concentrated in Northeast Houston US Census tracts in Harris County. The main drivers of increased risk in these areas include the proportion of the area that is impervious surface, consistently high social vulnerabilities, and poor health. However, the most vulnerable areas also have overlapping exposure to both industrial land use and floodplains. Assessing the contribution of a set of industrial land use, social vulnerability, natural hazard, emergency response, and topography variables in a single index on the same spatial scale (e.g., US Census tract) provides detailed information for policy makers tasked with mitigating risk. Applying tools such as the TMVI to highly vulnerable urban and coastal locations may help identify changes needed for preparedness and mitigation planning and highlight areas where limited resources for investment- and policy-related remediation should be focused, both before and after disasters.

The Impact of Social Vulnerability on COVID-19 in the U.S.: An Analysis of Spatially Varying Relationships

INTRODUCTION

Because of their inability to access adequate medical care, transportation, and nutrition, socially vulnerable populations are at an increased risk of health challenges during disasters. This study estimates the association between case counts of COVID-19 infection and social vulnerability in the U.S., identifying counties at increased vulnerability to the pandemic.

METHODS

Using Social Vulnerability Index and COVID-19 case count data, an ordinary least squares regression model was fitted to assess the global relationship between COVID-19 case counts and social vulnerability. Local relationships were assessed using a geographically weighted regression model, which is effective in exploring spatial nonstationarity.

RESULTS

As of May 12, 2020, a total of 1,320,909 people had been diagnosed with COVID-19 in the U.S. Of the counties included in this study (91.5%, 2,844 of 3,108), the highest case count was recorded in Trousdale, Tennessee (16,525.22 per 100,000) and the lowest in Tehama, California (1.54 per 100,000). At the global level, overall Social Vulnerability Index (eβ=1.65, p=0.03) and minority status and language (eβ=6.69, p<0.001) were associated with increased COVID-19 case counts. However, on the basis of the local geographically weighted model, the association between social vulnerability and COVID-19 varied among counties. Overall, minority status and language, household composition and transportation, and housing and disability predicted COVID-19 infection.

CONCLUSIONS

Large-scale disasters differentially affect the health of marginalized communities. In this study, minority status and language, household composition and transportation, and housing and disability predicted COVID-19 case counts in the U.S. Addressing the social factors that create poor health is essential to reducing inequities in the health impacts of disasters.

Estimating Evacuation Shelter Deficits in the Houston-Galveston Metropolitan Area

Evacuation is frequently used by emergency managers and other officials as part of an overall approach to reducing the morbidity and mortality associated with hurricane landfall. In this study, the evacuation shelter capacity of the Houston-Galveston Metropolitan Statistical Area (MSA) was spatially assessed and shelter deficits in the region were estimated. These data provide essential information needed to eliminate shelter deficits and ensure a successful evacuation from a future storm. Spatial statistical methods-Global Moran's I, Anselin Local Moran's I (Local Indicators of Spatial Association [LISA]), and Hot Spot Analysis (Getis-Ord Gi*) were used to assess for regional spatial autocorrelation and clustering of evacuation shelters in the Houston-Galveston MSA. Shelter deficits were estimated in four ways-the aggregate deficit for the Houston-Galveston MSA, by evacuation Zip-Zone, by county, and by distance or radii of evacuation Zip-Zone. Evacuation shelters were disproportionately distributed in the region, with lower capacity shelters clustered closer to evacuation Zip-Zones (50 miles from the Coastal Zip-Zone), and higher capacity shelters clustered farther away from the zones (120 miles from the Coastal Zip-Zone). The aggregate shelter deficit for the Houston-Galveston MSA was 353,713 persons. To reduce morbidity and mortality associated with future hurricanes in the Houston-Galveston MSA, authorities should consider the development and implementation of policies that would improve the evacuation shelter capacity of the region. Eliminating shelter deficits, which has been done successfully in the state of Florida, is an essential element of protecting the public from hurricane impacts.

Medicaid expansion and infant mortality, revisited: A difference-in-differences analysis

OBJECTIVE

To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States.

DATA SOURCES

State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research.

STUDY DESIGN

The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors.

PRINCIPAL FINDINGS

Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03).

CONCLUSIONS

Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.

Using the 12-item short form health survey (SF-12) to assess self rated health of an engaged population impacted by hurricane Harvey, Houston, TX

BACKGROUND

In the last decade there has been an increase in community-based organizations providing support and educational outreach to populations effected by hazards. Prior research has demonstrated various roles that community social capital can play in both the enhancement of disaster preparedness and the mitigation of physical and mental health impacts following a natural disaster.

METHODS

To assess self-reported health of residents of South Houston, Texas impacted by Hurricane Harvey, attendees of a community event completed a survey that included the 12 item short form health survey version 2 (SF-12v2).

RESULTS

Although survey participants were older and more likely to be African-American than the overall population of Houston, they had higher mental health composite scores that the national average, with increases in mental wellbeing associated with a longer length of residence in their neighborhood.

CONCLUSIONS

The City of Houston, with highly segregated, socially vulnerable populations at high risk from natural hazards, should consider ways to support community engagement around disaster preparedness, response, and recovery that may build community cohesion and improve post-disaster mental health.

A Spatial Analysis of Possible Environmental Exposures in Recreational Areas Impacted by Hurricane Harvey Flooding, Harris County, Texas

Hurricane Harvey made landfall on the Texas Gulf Coast in August 2017 causing catastrophic flooding. Harris County is highly vulnerable to flooding, which is controlled in part by a system of bayous that include parks and trails. The petrochemical industry, as well as thousands of documented sources of environmental pollution make recreational areas susceptible to environmental contamination during flood events. Recreational areas and toxic exposure sources were geocoded by subwatershed boundaries and overlaid with the area of Hurricane Harvey inundation. A total of 121 of 349 (36.78%) parks were flooded; 102 of 121 (84.30%) were located in subwatersheds with at least one exposure source. A total of 337 exposure sources (6 Superfund, 32 municipal solid waste, and 299 petroleum storage tanks) in 30 subwatersheds were flooded. Though parks provide flood mitigation and other postdisaster benefits, their susceptibility to environmental contamination should be considered, especially in areas with a large number of toxic exposure sources.

Using Spatial Analysis to Examine Potential Sources of Polycyclic Aromatic Hydrocarbons in an Environmental Justice Community After Hurricane Harvey

Polycyclic aromatic hydrocarbons (PAHs) are environmental contaminants associated with adverse human health outcomes. Environmental justice neighborhoods experience disproportionate environmental health risks. Hurricane Harvey made landfall on August 25, 2017, bringing record rainfall and catastrophic flooding to Houston, Texas, redistributing PAHs in residential soil. We aimed to describe PAH distributions in soil in the Manchester neighborhood of Houston, TX, and identify their potential sources. Soil samples were collected from 24 residential addresses and analyzed for 16 priority PAH concentrations using an accelerated solvent extractor. PAH distribution and source determination were conducted using spatial analysis and isomer ratios. All sample sites detected PAHs in soil, with the total mass ranging from 0.75 to 69.9 ng/g, which were predominantly four-ring structured PAHs. Total PAH concentrations were highest on the northeastern border of the neighborhood, whereas lower overall concentrations of PAHs were found on the southwestern border, at the highest elevation in the watershed. The ratio indeno[1,,3-cd]pyrene (IP) to indeno[1,,3-cd]pyrene plus benzo[ghi]perylene indicated vehicular combustion as the primary source in 19 of 23 samples. After heavy rainfall from Hurricane Harvey in the Manchester neighborhood, PAHs in soil were unevenly distributed throughout the neighborhood, with an accumulation of PAHs in the northeastern edges. Using isomer ratios and spatial analysis, the likely source of PAHs is from use of transportation infrastructure.

Improving Hurricane Harvey Disaster Research Response Through Academic-Practice Partnerships

After Hurricane Harvey, researchers, media, and public health agencies collected data in Houston, Texas, to assess potential health effects and inform the public. To limit redundancy and ensure sampling coverage of impacted areas, research and practice partners used disaster research response (DR2) resources and relied on partnerships formed during a 2015 DR2 workshop in Houston. Improved coordination after the disaster can improve the effectiveness and efficiency of DR2 and enable the use of data to improve recovery and preparedness for future disasters.

Demographic Determinants of Influenza Vaccination and Infection, Brazos County, Texas, 2017

BACKGROUND

Seasonal influenza constitutes an enormous public health burden. The 2017-2018 influenza season was the most severe since the 2009 novel Influenza A (H1N1) pandemic. The State of Texas, like other states, experienced unusually high and persistent influenza activity.

METHODS

Data on confirmed cases of influenza and influenza-like illness (ILI) in Brazos County during December 2017 were collected by the Brazos County Health Department (BCHD) from medical records. Records of vaccine administered between January 1 and December 31, 2017 were collected from vaccination providers. The total number of influenza cases for 2017 was compiled from regular weekly influenza counts reported to BCHD by healthcare providers.

RESULTS

A total of 1651 cases of laboratory-confirmed influenza were reported in Brazos County residents in December 2017, 10 times more than that reported in December 2016. The highest rates of infection were in 2 ZIP codes where vaccination rates were also high. A total of 16 027 influenza vaccinations were given to individuals reporting a residential address in Brazos County in 2017. Vaccination coverage was lowest among adults aged 18 to 49, whereas those aged 65 or older and Hispanics were most likely to be hospitalized.

DISCUSSION

Overall, vaccination coverage in Brazos County, Texas is low, less than half of the Healthy People 2020 target. The development of health education materials and an increased use of social media, local television and radio, and communication methods that can reach parents, younger adults, and Hispanic residents are needed.

Engaged Environmental Science for Underserved Youth

The National Institute for Environmental Health Sciences has called for targeted efforts to engage underserved youth in environmental education programs that support environmental literacy and contribute to the development of a diverse workforce pipeline for environmental science-related occupations. Evidence suggests that career knowledge among low income and minority youth is more likely to be incompatible with post-secondary educational opportunities than other racial and ethnic groups. One approach to attenuating discordant college and career expectations among underserved youth is building networks for information sharing between secondary and post-secondary students. The purpose of this commentary is to describe the development and implementation of a high school curriculum on environmental science and environmental justice by Texas A&M University in collaboration with community engagement partners, students, and teachers at Furr High School, an innovative XQ Super School in Houston, Texas.

Evacuation Shelter Deficits for Socially Vulnerable Texas Residents During Hurricane Harvey

Background:

Socially vulnerable residents of US Gulf Coast counties have higher exposure to physical hazards and disaster-associated risks. Evacuation is one way to mitigate the consequences of disaster exposure among socially vulnerable populations. However, it is unknown whether existing evacuation shelter capacity and locations in designated hurricane evacuation zones of Texas are adequate to accommodate persons with housing and transportation needs. This study estimated the evacuation shelter deficit arising from demand from socially vulnerable residents of the Houston-Galveston area.

Methods:

Spatial statistical methods including Global Moran’s I and Getis-Ord (Gi*) were used to measure spatial autocorrelation and identify census tracts in the study area with high (hot spots) and low (cold spots) social vulnerability in both housing and transportation domains. The shelter deficit in each county within the study area was estimated as well as for the entire Houston-Galveston Metropolitan Statistical Area.

Results:

Designated evacuation zones in the Houston-Galveston area have an overall shelter deficit of 163 317 persons. Shelters in the area can only accommodate 36% of evacuees with significant housing and transportation needs, while 3 of 4 counties had county-specific evacuation shelter deficits. The highest deficits were in Harris County, where Houston is located, and the lowest were in Matagorda County, a rural county southwest of Harris County.

Conclusion:

Emergency managers and other authorities should consider data related to demand from socially vulnerable residents for public shelters during disasters and increase shelter capacity in certain locations to address evacuation shelter shortage for vulnerable persons in designated evacuation zones of Texas.

Evaluating the Impact of Race and Gender on Environmental Risk Perceptions in the Houston Neighborhood of Manchester

Previous research has shown that white males tend to perceive risks from environmental exposures as lower than women and members of minority populations, often referred to as the white male effect. However, this effect was mostly demonstrated without regard to the actual lived environment experienced by the study participants. There is growing evidence that differences in risk perceptions cannot be adequately explained through race or gender. This cross-sectional study collected survey data from residents of Manchester, a small neighborhood in Houston, Texas, characterized by industrial sites, unimproved infrastructure, nuisance flooding, and poor air quality. Trained community members attempted a complete census within the geographically compact neighborhood. Logistic regression was used to estimate the relative effect of race on environmental health perceptions adjusted for generational age. In contrast to previous research, our study (N = 109) showed that nonwhite individuals perceived a lower environmental health risk compared with their white counterparts. Comparing female and minority racial groups with white males showed that on most issues, white males had the highest perception of risk. For example, adjusted for age, nonwhite respondents perceived the risk of contact with standing water as significantly lower than white respondents (odds ratio = 0.34; 95% confidence interval = 0.12-0.93). This study supports the hypothesis that when environmental conditions experienced by individuals are the same, minority groups tend to underestimate their risk compared with white males. One possible explanation put forth is that communal norms are created within minority populations through generations of exposure to negative environmental conditions compared with white populations.

Factors associated with dependence on smokeless tobacco, Navi Mumbai, India

Objective

Nearly 300 million people in India use some type of tobacco product, with about 60% of those using smokeless tobacco. Smokeless tobacco use has been associated with a number adverse health outcomes in India and across South Asia.

Method

A cross-sectional study of outpatients at a dental hospital in Navi Mumbai, India was conducted between January and June 2015. Trained interviewers administered a 19-item questionnaire to all patients receiving regular dental care. In addition to demographic information, data about the use of smokeless tobacco was collected. Nicotine dependence was assessed using the six-item Fagerstrom Nicotine Dependence Scale, adapted for smokeless tobacco.

Results

Approximately one third of 1,067 respondents (30.55%; N = 326) reported use of smokeless tobacco. Neither use of smokeless tobacco nor nicotine dependence was associated with any demographic variables. High nicotine dependence was associated with a younger age of initiation of smokeless tobacco use (RD = 0.14; 95% CI: 0.03, 0.25) and with frequency of use, with those who reported daily use having an excess risk of high nicotine dependence of 14% (95% CI: 2%, 27%).

Conclusion

To reduce dependence on smokeless tobacco in India and subsequent adverse health outcomes, interventions should emphasize a combination of policy and public health interventions focused on increasing the age at which a person initially uses smokeless tobacco and decreasing the frequency of use.

Validating a comprehensive plan scoring system for healthy community design in League City, Texas

Comprehensive plans provide an overall vision for a city's land use and development and influence community health conditions. As part of a community-engaged research project, a Healthy Living and Active Design Scorecard was applied to the comprehensive plan of League City, Texas, to identify health-promoting design and planning strategies. Although the plan scored similarly to published examples, several areas of improvement aligned with priorities from a community health assessment were identified, including improving public transportation and access to exercise and recreation. Future revisions of the plans and neighbourhood scaled designs targeting these issues could improve the health of the community.

Domestic Exposures to Polycyclic Aromatic Hydrocarbons in a Houston, Texas, Environmental Justice Neighborhood

Polycyclic aromatic hydrocarbons (PAHs) are a class of >100 chemicals that naturally occur in coal tar, crude oil, and gasoline and can be manufactured as part of dyes, plastics, and pesticides. PAHs are complex environmental toxicants and exposure to them have been linked to adverse health outcomes including cancer, as well as diseases of the skin, liver, and immune system. Residents of the environmental justice neighborhood of Manchester, located on Houston's East End, are disproportionally exposed to toxic pollutants from both industry and transportation infrastructure. Based on a longstanding community engagement partnership with the research team, neighborhood residents sought to better understand their domestic exposure to PAHs. Particulate wipes were used to collect dust from a marked area within the entryway of randomly selected homes to assess for the presence of PAHs. Nineteen of the 61 PAH analytes, including the Environmental Protection Administration's 16 priority PAHs and the subgroup of 7 probable human carcinogens, were found in the sampled homes. Residents of the Houston neighborhood of Manchester potentially have significant domestic exposure to PAHs from combustion sources. More research is needed to assess the source of the PAHs and to better understand the potential health impacts of these exposures.

The development of a participatory assessment technique for infrastructure: Neighborhood-level monitoring towards sustainable infrastructure systems

Climate change and increasing natural disasters coupled with years of deferred maintenance have added pressure to infrastructure in urban areas. Thus, monitoring for failure of these systems is crucial to prevent future impacts to life and property. Participatory assessment technique for infrastructure provides a community-based approach to assess the capacity and physical condition of infrastructure. Furthermore, a participatory assessment technique for infrastructure can encourage grassroots activism that engages residents, researchers, and planners in the identification of sustainable development concerns and solutions. As climate change impacts disproportionately affect historically disenfranchised communities, assessment data can further inform planning, aiming to balance the distribution of public resources towards sustainability and justice. This paper explains the development of the participatory assessment technique for infrastructure that can provide empirical data about the condition of infrastructure at the neighborhood-level, using stormwater systems in a vulnerable neighborhood in Houston, Texas as a case study. This paper argues for the opportunity of participatory methods to address needs in infrastructure assessment and describes the ongoing project testing the best use of these methods.

Comparing residential contamination in a Houston environmental justice neighborhood before and after Hurricane Harvey

Introduction

Polycyclic aromatic hydrocarbons (PAHs) are complex environmental toxicants. Exposure to them has been linked to adverse health outcomes including cancer, as well as diseases of the skin, liver, and immune system. Based on an ongoing community engagement partnership with stakeholder groups and residents, we conducted a small longitudinal study to assess domestic exposure to PAHs among residents of Manchester, an environmental justice neighborhood located in the East End of Houston, TX.

Methods

In December, 2016, we used fiber wipes to collect samples of household dust from 25 homes in Manchester. Following Hurricane Harvey, in September 2017, we revisited 24 of the 25 homes to collect soil samples from the front yards of the same homes. Wipes and soil were analyzed for the presence of PAHs using gas chromatography–mass spectrometry (GC-MS) methods. Principal component analysis plots, heatmaps, and PAH ratios were used to compare pre- and post-Hurricane Harvey samples.

Results

While direct comparison is not possible, we present three methods for comparing PAHs found in pre-hurricane fiber wipes and post-hurricane soil samples. The methods demonstrate that the PAHs found before and after Hurricane Harvey are likely from similar sources and that those sources are most likely to be associated with combustion. We also found evidence of redistribution of PAHs due to extreme flooding associated with Hurricane Harvey.

Discussion

Residents of the Manchester neighborhood of Houston, TX, are exposed to a range of PAHs in household dust and outdoor soil. While it was not possible to compare directly, we were able to use several methods to assess detected concentrations, changes in site-specific PAH allocations, and PAH origination. Additional research is needed to identify specific sources of domestic PAH exposure in these communities and continued work involving community members and policy makers should aim to develop interventions to reduce domestic exposure to and prevent negative health outcomes from PAHs.

History of Disaster Epidemiology

Disaster epidemiology is not a new field, and the methods utilized to conduct disaster epidemiology studies are no different than the methods used in everyday applied public health research and investigations. The only difference is the circumstances under which the methods are employed. The challenges of conducting epidemiologic studies during a disaster are many—limited access to study sites and populations; access to reliable electricity, connectivity, and communication systems; and typically a short time frame in which to gather, analyze, and report data to decision-makers so that it can be utilized to prevent morbidity and mortality. However, many innovations have been developed by disaster epidemiologists to meet these challenges. Rapid needs assessments, innovative surveillance and tracking systems, and adapted epidemiologic study designs are some of the innovations that will be discussed in this chapter.

How Health Department Contextual Factors Affect Public Health Preparedness (PHP) and Perceptions of the 15 PHP Capabilities

OBJECTIVES

To assess how health department contextual factors influence perceptions of the 15 Public Health Preparedness Capabilities, developed by the Centers for Disease Control and Prevention (CDC) to provide guidance on organizing preparedness activities.

METHODS

We conducted an online survey and focus group between September 2015 and May 2016 with directors of preparedness programs in state, metropolitan, and territorial jurisdictions funded by CDC's Public Health Emergency Preparedness (PHEP) cooperative agreement. The survey collected demographic information and data on contextual factors including leadership, partnerships, organizational structure, resources and structural capacity, and data and evaluation.

RESULTS

Seventy-seven percent (48 of 62) of PHEP directors completed the survey and 8 participated in the focus group. Respondents were experienced directors (mean = 10.6 years), and 58% led 7 or more emergency responses. Leadership, partnerships, and access to fiscal and human resources were associated with perception and use of the capabilities.

CONCLUSIONS

Despite some deficiencies, PHEP awardees believe the capabilities provide useful guidance and a flexible framework for organizing their work. Contextual factors affect perceptions of the capabilities and possibly the effectiveness of their use. Public Health Implications. The capabilities can be used to address challenges in preparedness, including identifying evidence-based practices, developing performance measures, and improving responses.