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Health Effects of Wildfires
Sumi Hoshiko, MPH California Department of Public Health
California Climate Action Team Public Health Workgroup (CAT-PHWG)
Sacramento, CA June 10, 2019
1 Center for Healthy Communities
Environmental Health Investigations Branch
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Disclosures
• No conflicts of interest
The contents of this report are solely the responsibility of the author and do not necessarily represent the official views of the California Department of Public Health or any other agency or entity. The published research described in this presentation has been reviewed by the California Department of Public Health and approved for publication. Approval does not signify that the contents necessarily reflect the views and policies of the agency.
2 Center for Healthy Communities
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2018 November
The Camp Fire is now the most destructive fire in California history.
https://wjla.com/news/nation-world/death-toll-wildfires-northern-southern-california
3 Center for Healthy Communities
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Center for Healthy Communities Environmental Health Investigations Branch
Multiple and fast spreading
fires, easily jumped what would
normally serve as a fire break,
6-lane Highway https://www.youtube.com/watch?v=opVz7HZAXLo 101
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American College of Toxicology • 38th Annual Meeting • November 5−8, 2017
Patients being evacuated from Santa Rosa Hospital While
thousands of residents were
under evacuation
orders, hospitals
threatened by fires were also
having to evacuate patients.
Environmental Health Investigations Branch Center for Healthy Communities
California Department of Public Health
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HAIR 50-?0µm
(microns) in diameter
... .. 90 µm (microns) in diameter
FINE BEACH SAND
PM2.s Combustion particles, organic
compounds, metals, etc. < 2.5 µm (microns) in diameter
PM10 Dust, pollen, mold, etc.
< 1 0 µm (microns) in diameter
Environmental Health Investigations BranchCenter for Healthy Communities
California Department of Public Health
American College of Toxicology • 38th Annual Meeting • November 5−8, 2017
smaller.
Particulate matter
PM10 : inhalable p articles, with diameters that are generally 10 micrometers and smaller
PM2.5 : fine inhalable particles, with diameters that are generally 2.5 micrometers and
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I: A ct:
San F
~~ •"C~PH 7 alif: rnia Publi p rnncn f c Health
Center for Healthy Communities Environmental Health Investigations Branch
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Center for Healthy Communities Environmental Health Investigations Branch
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Center for Healthy Communities Environmental Health Investigations Branch
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_
San
.Jose
Center for Healthy Communities Environmental Health Investigations Branch
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.
\ -~-------- /
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. n ..Jose
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Center for Healthy Communities Environmental Health Investigations Branch
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Air-quality impacts extend hundreds of miles
=> distant urban areas • Forest fires in Quebec,
Canada, 2002
• Baltimore, Maryland, nearly 1,000 miles downwind
• 30-fold increase in airborne fine particle concentrations
Source: Moderate Resolution Imaging Spectroradiometer (MODIS) instrument on the Terra satellite, Land Rapid Response
Team, NASA/GSFC
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Center for Healthy Communities Environmental Health Investigations Branch
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Center for Healthy Communities Environmental Health Investigations Branch
Global mortality attributable to wildfire smoke: Johnson FH et al. 2012
Estimated to be 339,000 persons Global Fire Map 2/20/2016 – 2/29/2016 URL: lance-modis.eosdis.nasa.gov/cgi-bin/imagery/firemaps.cgi
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000
3,000,000
5,000,000
7,000,000
9,000,000
000,000
Increasing Wildfire Risk in the U.S. 11, 11
Acreage Burned in 9
the U.S. 7
5
3
1
Annually
Acr
es B
urne
d (in
mill
ions
)
1,000, 1965 1975 1985 1995 2005 2015
Radeloff et al. 2005 Adapted from https://www.nifc.gov/fireInfo/fireInfo_stats_totalFires.html
Center for Healthy Communities Environmental Health Investigations Branch
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Drought -- 129 Million Dead Trees
Center for Healthy Communities Environmental Health Investigations Branch
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Center for Healthy Communities Environmental Health Investigations Branch
Increasing Wildfire Risk
to Human Populations:
Wildland– Urban
Interface (“WUI”)
• 38% of U.S. housing units near wildland
headwaterseconomics.org/wildfire/homes-risk/northern california homes and cost of wildfires
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Fires from Agricultural and
Prescribed (controlled) Burns Agricultural fires and prescribed burns account for 70% of total number of fires in U.S.
CO2 emissions increasing NASA 2012
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Agricultural fires
Active fires (#/yr)
0 10 20 30 40 50
Center for Healthy Communities Environmental Health Investigations Branch
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Wildfire smoke is a complex mixture of gases and particles Depends on fuel & combustion conditions
Gases • Combustion products
– Carbon monoxide – Nitrogen monoxide – Carbon dioxide
• Products of secondaryphotochemical processes – Ozone – Nitrogen dioxide
Particles
• Organic compounds – Polycyclic Aromatic Hydrocarbons – Organic acids: carboxylic acids – Aldehydes, formaldehyde
• Inorganic materials, traceelements: – - K, Mg, P, Mn
• Free radicals – mainly organic
Fowler 2003; Kunzli 2006; Caamano-Isorna 2011; Vishal, 2009.
Center for Healthy Communities Environmental Health Investigations Branch
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Center for Healthy CommunitiesEnvironmental Health Investigations Branch
Wildfires increasing ambient air pollution
Wildfires contributed 20% of the particulate
matter in ambient air
pollution, 2012
https://www.epa.gov/air-emissions-inventories/2011-national-emissions-inventory-nei-data
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Center for Healthy Communities Environmental Health Investigations Branch
• Important to remember that not everyone exposed to wildfire smoke will have health problems.
Duration & level of exposure, age, individual susceptibility, pre-existing lung or heart disease, etc.
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Wildfire particulate matter
• Penetrates deeply into the alveolar region of the lung
• Damage to cilia • Loss of epithelial cells • Crosses into the
bloodstream
Wegesser TC et al, California wildfires of 2008: coarse and fine particulate matter toxicity. Environ Health Perspect.. 2009;117:893-7
Center for Healthy Communities Environmental Health Investigations Branch
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Health effects known or suspected to be caused by wildfire smoke
• Eye irritation, sore throat, wheeze & cough
• Asthma & COPD exacerbations • Bronchitis & pneumonia • Cardiovascular outcomes • Adverse birth outcomes • All-cause mortality
Center for Healthy Communities Environmental Health Investigations Branch
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Asthma Action Plan cdc.gov/ASTHMNactionplan. html
Respiratory morbidity Very consistent evidence from a large number of studies Reviewed by Reid et al 2016.
Asthma • Very consistent evidence from a large number of studies • Most commonly studied, most clearly affected outcome,
based on hospitalization and ED visits • Also studies on medication use, physician visits
COPD • Very consistent associations (fewer studies than asthma)
Respiratory infections • Associated (fewer studies than asthma)
Infectious conditions - pneumonia and bronchitis • Associated (fewer studies than asthma)
Center for Healthy Communities Environmental Health Investigations Branch
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Cardiovascular morbidity
• Often mixed / inconclusive / null - 16 evaluations of cardiovascular morbidity overall – generally null (Reid et al 2016)
• Not as many studies looked at cardio compared to respiratory • CV events much rarer than respiratory, e.g. asthma
– harder to study
• Too broad a category? - relatively few studies look at separate endpoints within cardiovascular
Center for Healthy Communities Environmental Health Investigations Branch
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=- 20 0
~ 16 0) ._..
~ 12 ns -5 8 Cl) C') ns ....., C Cl) (.) I.. Cl)
c..
4
0
-4
Out-of-Hospital Cardiac Arrest (OHCA)
OHCA >65 Men Total years
8
0
~ 6 It) 0) ._.. Cl)
g> 4 ns .c (.)
& 2 ns ....., C Cl)
~ 0 Cl) c..
-2
lschemic Heart Disease {IHD) Hospitalizations
IHD >65 years
Women
Environmental Health Investigations BranchCenter for Healthy Communities
California Department of Public Health
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Cardiovascular effects Victoria, Australia - Dec 1, 2006 - Jan 31, 2007
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Natural disasters → Psychological impacts
WILDFIRES
• Spain: ↑ anti-anxiety RX use in months following wildfires
• Greece: depression, paranoia, psychopathology
• Los Angeles fire victims: sleep disturbances, nightmares
Center for Healthy Communities Environmental Health Investigations Branch
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Vulnerable populations • Young and old are
susceptible • Pre-existing conditions,
e.g. – respiratory – cardiovascular – diabetic
• Outdoor workers
Center for Healthy Communities Environmental Health Investigations Branch
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Wildfire Susceptible Populations NHANES 2007-2010
Susceptible category N Percent (95% CI)
None 7135 73.0 (71.4, 74.6)
Respiratory only 642 6.4 (5.5, 7.2)
Cardiovascular only 319 2.6 (2.3, 2.9)
>65 years only 1713 10.9 (10.1, 11.8)
Respiratory and cardiovascular 136 1.0 (0.7, 1.3)
Respiratory and >65 years 220 1.6 (1.3, 1.8)
Cardiovascular and >65 608 3.8 (3.3, 4.3) years
All three groups 125 0.7 (0.5, 0.9)
NHANES = National Health and Nutrition Education Survey Wells EM, Dearborn DG, Jackson LW (2012). PLoS ONE 7(11): e50526
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642 6.4 (5.5, 7.2)
319 2.6 (2.3, 2.9)
1713 10.9 (10.1, 11.8)
136 1.0 (0.7, 1.3)
220 1.6 (1.3, 1.8)
608 3.8 (3.3, 4.3)
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Wildfire Susceptible Populations NHANES 2007-2010
Susceptible category N Percent (95% CI)
None 7135 73.0 (71.4, 74.6)
Respiratory only
Cardiovascular only
>65 years only
Respiratory and cardiovascular
Respiratory and >65 years
Cardiovascular and >65 years
All three groups 125
NHANES = National Health and Nutrition Education Survey Wells EM, Dearborn DG, Jackson LW (2012). PLoS ONE 7(11): e50526
27% fall into at least one susceptible
group
0.7 (0.5, 0.9)
Center for Healthy Communities Environmental Health Investigations Branch
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No effect level
~~ •"C~PH 7 alif: rnia Publi p rnncn f c Health
Lago
All Lag1
Lag2
Lag3
Lago
ndig,enous Lag1
Lag2
Lag3
Lago
Non- lndi9enous Lag1 Lag2
Lag3
COPD
0.6 0.8 rn 1,2 1.4 1.6 1,8 2.0
Odds Ratio (log scale)
Vulnerable Populations: General
population: Indigenous vs. ~20%
Non-indigenous increase in COPD
COPD Hospital admissions
Australia
Adjusted Odds Ratios, 95% Confidence IntervaI, per 10ug/m3 increase in PM10
Johnston FH, Bailie RS, Pilotto LS, Hanigan IC. Ambient biomass smoke and cardio-respiratory hospital admissions in Darwin, Australia. BMC Public Health. 2007 Sep 13;7:240.
Center for Healthy Communities Environmental Health Investigations Branch
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No effect level
~~ •"C~PH 7 alif: rnia Publi p rnncn f c Health
Lago
All Lag1
Lag2
Lag3
Lago
ndig,enous Lag1
Lag2
Lag3
Lago
Non- lndi9enous Lag1 Lag2
Lag3
COPD
0.6 0.8 rn 1,2 1.4 1.6 1,8 2.0
Odds Ratio (log scale)
Vulnerable Populations: Indigenous vs.
Non-indigenous
COPD Hospital admissions
Australia
Adjusted Odds Ratios, 95% Confidence IntervaI, per 10ug/m3 increase in PM10
General population: ~20% increase in COPD
Indigenous population: ~200% increase in COPD (log scale)
Johnston FH, Bailie RS, Pilotto LS, Hanigan IC. Ambient biomass smoke and cardio-respiratory hospital admissions in Darwin, Australia. BMC Public Health. 2007 Sep 13;7:240.
Center for Healthy Communities Environmental Health Investigations Branch
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California
• 9,000 separate wildfires
• >1,000,000 acres burned
San Diego
• Medi-Cal population
• San Diego firestorm
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o 500,000 evacuated
o Mult iple school & road closings
P 1, ~QI lo-,tl ~ , COn<t,on W ...... ~ _,.._,. IINI••""" to< $0nslllw,GIO<IPI
• """ .. """"' v • ..,. u,_iv, -~.,.,_,. San Diego Region
ZIP CODES
,;, I ..... 10 I.I -----• I ~ U ~ -SIIMMG
F~rv1013
9225,9
San Diego 2007 Wildfire Research Study: Collaboration with San Diego County, Michigan Tech Research Institute
Center for Healthy Communities Environmental Health Investigations Branch
3322
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-C")
E ---0)
800 - ------------------ Average
600 -
Daily average PM25 (by zip)
US EPA 24hr PM standard (35µg/m3)
3 400 -l!)
C'\i
I 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5
October 2007 I November 2007
Daily PM2.5
33 Center for Healthy Communities
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Respiratory (all) Carrdiovas,cullar (all ) Total Encou nt,ers,
2.0i ---------------------------
a:: a::
t.5,
1.0
0.5,
1--5
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f 6-10 111-15
+ ■
11--5 6--1 0 11 -1 5, 1--5 6-10 111-15 da,y:s
Visit Type
+ Emergency Presentations ¼ I npatiient Hospitalizations
+ Outpatient Visits
Respiratory and cardiovascular visits San Diego County during 2007 fire period
34 Center for Healthy Communities
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2.0
0::: o::: 1.5 t
Asthma
Upper Respiratory
Infection
Respiratory Symptoms Acute Bronchitis
'
II
I
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days
Visit Type
+ Emergency Presentations ¼ lnpatiient Hospitalizations
+ Outpatient Visits
Respiratory visits
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Asthma
2.5~------
2.0
0::: o::: 1.5 t 1.0- _,__ _ _
Upper Respiratory
Infection
Respiratory Symptoms cute Bronchitis
Bronchitis (not specified) Pneumonia COP□
0.5------- --------- ---------------------------- .......... -------~· L__J L__J L__J L__J L__J L__J L__J L__J L__J
1-5 6-10 111-15 1-5 '6-10 11-15 1-5 '6-10 11-15
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L__J L__J L__J L__J L__J L__J
1-5 6-1 0 11 -15 1-5 6-1 0 11 -1 5
Visit Type
+ Emergency Presentations
¼ lnpatiient Hospitalizations
+ Outpatient Visits
Respiratory visits
36 Center for Healthy Communities
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Asthma
2.5~------
2.0
0::: o::: 1.5 t 1.0- _,__ _ _
Upper Respiratory
Infection
Respiratory Symptoms
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Acute Bronchitis
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L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J L__J
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1-5 6-1 0 11 -1 5
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Visit Type
+ Emergency Presentations
¼ lnpatiient Hospitalizations
+ Outpatient Visits
Respiratory visits
37 Center for Healthy Communities
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l~ \!_ 11', ~ -· \ RR -~ ntJ %~ 0 ....i. N u)
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I I • 1-• I ► i t Upper Respiratory Infection [ • • 1 I )> ! • ... I co
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Center for H
ealthy Com
munities
Environmental H
ealth Investigations Branch
Respiratory visits, by age group
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,
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Center for H
ealthy Com
munities
Environmental H
ealth Investigations Branch
Respiratory visits, by age group
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Center for Healthy Communities Environmental Health Investigations Branch
Air Quality Index (AQI) Odds Ratios (ORs), conditional logistic regression of respiratory emergency department visits
AQI categories PM2.5 (µg/ m3)
OR (95% CI) Same day
OR (95% CI) 1-day lag
OR (95% CI) 2-day lag
Good (0 -12)
Moderate (12.1 - 35.4)
Unhealthy for Sensitive Groups (35.5 - 55.4) Unhealthy (55.5 - 150.4) Very unhealthy (150.5 - 250.4) Hazardous (≥ 250.5)
Temperature
Relative humidity AIC
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Center for Healthy Communities Environmental Health Investigations Branch
Air Quality Index (AQI) Odds Ratios (ORs), conditional logistic regression of respiratory emergency department visits
AQI categories PM2.5 (µg/ m3)
OR (95% CI) Same day
OR (95% CI) 1-day lag
OR (95% CI) 2-day lag
Good (0 -12) Reference Reference Reference
Moderate (12.1 - 35.4) 1.20 (0.91-1.59) 1.11 (0.84-1.47) 0.80 (0.59-1.08)
Unhealthy for Sensitive Groups (35.5 - 55.4)
1.43 (0.96-2.13) 1.73 (1.18-2.53)* 1.51 (1.00-2.28)*
Unhealthy (55.5 - 150.4)
1.27 (0.97-1.67) 1.79 (1.30-2.23)* 1.50 (1.13-1.98)*
Very unhealthy (150.5 - 250.4)
1.68 (1.00-2.83) 1.58 (0.93-2.68) 1.87 (1.07-3.27)*
Hazardous (≥ 250.5) 2.41 (1.39-4.18)* 1.28 (0.70-2.36) 1.74 (1.00-3.03)*
Temperature 1.00 (0.99-1.01) 1.00 (0.99-1.01) 1.00 (0.99-1.00)
Relative humidity 1.01 (1.00-1.01)* 1.01 (1.00-1.01)* 1.01 (1.00-1.01)* AIC 5233.2 5228.9 5231.8
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CARDIOVASCULAR EFFECTS & WILDFIRE SMOKE 2015 WILDFIRES
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Number of Smoky Days per County:
May 1 through September 30, 2015
W ettstein ZS 1, Hoshiko s~, Fahimi J>, Harrison RJ4,5 , Cascio W E6 , Rappold AG7. J Am Heart Assoc. Cardiovascular and Cerebrovascular Emer!ilency Department V1s1ts Associated
With Wildfire Smoke Exposure in California in 2015. 2018 Apr 11 ;7(8).
• Lo&l\n{lell,&
• S/Jn D,eoo
CDPH Collaborative Research
Center for Healthy Communities Environmental Health Investigations Branch
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All-cause Cardiovascular
1.2-
1 .1 -
+ a:: 0::: 1 .0
0 .9-
0 .8-
'•i • ----Light Medium Dense
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All-cause Stroke All-cause Respiratory
Light Medium Dense Light Medium Dense Smoke Density
Appendicitis
Light Medium Dense
Age Category • Adults 19- 44 ♦ Adults 45-64 ♦ Adults 65+
Cardiovascular and other ER visits ↑ Risks from light, medium and dense smoke -- Adults 65+
No consistent relationship seen with younger adults.
Center for Healthy Communities Environmental Health Investigations Branch
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Smoke Sense
,•J~ c~D1:H,
alifomia p Ith PublicHea
TAMERICAN LUNG ASSOCIATION®
SmokeSense Mobile App:
A collaborative citizen science research project
developed by US EPA
The California Department of Public Health with support from
the American Lung Association is collaborating with US EPA
to analyze data from SmokeSense
Center for Healthy Communities Environmental Health Investigations Branch
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.. ,. ~---Momnk!DROMI•
NMbtta y,-.,,.
SIMtnttolilRAh NII
Public Health Guidance Resource:
Smoke Sense
Wildfire Smoke: A guide for public health officials https://www3.epa.gov/airnow/wildfire_may2016.pdf
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USEPA – AirNow Resources Download https://www.airnow.gov/ SmokeSense
EPA Citizen Science Project
Mobile App
Supported in part by the American Lung
Association
Nixle: Sign up to get up-to-date local public safety
and school info http://www.nixle.com/
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Fires and Your Health
Particle Pollution and Your Patients' Health
Smoke is made up of a complex
mixture of gases and fine part icles produced when
wood and other organic materials burn . The biggest
health threat from smoke is from fine particles. These
microscopic pa rti cl es can get into your eyes and
respiratory system, where
the can cause health roblems such as burnin e es runn nose
~~ ~ ~~R!i
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Officials,
• HowSm1 Can Affe,
• Particle I rn th iol ical mechanisms sibl for the Your Hea
• Other Ail I ov scula nd r spir tory ealth assoo ted Publicati
Exit AirNow
• Before, [ a Wildfir,
Informat1 emergen,
llution xpo ur .
uc t onal tools to h Ip pati nts und r tand how pollution exposur can ff ct th 1r h alth and how
r can use he Air Quality Index to protect their health.
CONTACT US
SHARE CD 0 ®@
This course is
designed for fami ly
med icine physicians,
internists,
ped iatric ians,
occupational and
rehab ilitation
physicians, nu rse
practit ioners, nu rses,
asthma educators,
pulmonary spec ialists,
cardiologists, and
other medical
Resources
USEPA – CME Education USEPA – AirNow Fires and Your Health
https://airnow.gov/index.php/air-quality-and-health/fires-and-your-health
https://www.epa.gov/pmcourse/continuing-education-particle-pollution-course
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Acknowledgements The San Diego 2007 wildfires and Medi-Cal emergency department presentations,
inpatient hospitalizations, and outpatient visits Sumi Hoshiko, MPH
California Department of Public Health
Justine Hutchinson, PhD Jason Vargo, PhD
Meredith Milet, MPH
Michigan Technological University Nancy HF French, PhD
Michael Billmire
San Diego County Health and Human Services Agency
Jeffrey Johnson, MPH
PlosMed; 2018 Jul 10;15(7):e1002601.
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Acknowledgements: Cardiovascular and Cerebrovascular Emergency Department Visits Associated With Wildfire
Smoke Exposure in California in 2015.
Zachary Wettstein, MD (right in photo) University of California San Francisco
Sumi Hoshiko, MPH California Department of Public Health California Department of Public Health Environmental Health Investigations Branch
Robert Harrison, MD, MPH (left in photo) University of California San Francisco
Division of Occupational and Environmental Medicine California Department of Public Health
Occupational Health Branch Ana G. Rappold, PhD US Environmental Protection Agency National Health and Environmental Effects Research Lab
Jahan Fahimi, MD, PhD University of California San Francisco
Wayne E. Cascio, MD Department of Emergency Medicine US Environmental Protection Agency
National Health and Environmental Effects Research Lab
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THANK YOU!
Sumi Hoshiko, MPH
Environmental Health Investigations Branch
California Department of Public Health
[email protected]
Center for Healthy Communities Environmental Health Investigations Branch
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