ww2.arb.ca.gov€¦ · ~-J~ ~ ~~p!j . PublicHealth . Disclosures • No conflicts of interest . The...

~-J~ ~ ~~ p!j

PublicHealth

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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PublicHealth

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.



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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



https://wjla.com/news/nation-world/death-toll-wildfires-northern-southern-california

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

https://www.youtube.com/watch?v=opVz7HZAXLo

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

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


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

I: A ct:

San F

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_

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.Jose


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. n ..Jose

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PublicHealth

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

12



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

https://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


https://www.nifc.gov/fireInfo/fireInfo_stats_totalFires.html

Drought -- 129 Million Dead Trees


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PublicHealth


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

https://headwaterseconomics.org/wildfire/homes-risk/northern

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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PublicHealth

Agricultural fires

Active fires (#/yr)

0 10 20 30 40 50


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PublicHealth

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 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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PublicHealth


• 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


http://www.ncbi.nlm.nih.gov/pubmed/19590679

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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


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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)


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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


=- 20 0

~ 16 0) ._..

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c..

4

0

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Out-of-Hospital Cardiac Arrest (OHCA)

OHCA >65 Men Total years

8

0

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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


25

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


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PublicHealth

Vulnerable populations • Young and old are

susceptible • Pre-existing conditions,

e.g. – respiratory – cardiovascular – diabetic

• Outdoor workers


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PublicHealth

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


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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PublicHealth

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)


No effect level


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.


http://www.ncbi.nlm.nih.gov/pubmed/?term=Johnston%20FH%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bailie%20RS%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed/?term=Pilotto%20LS%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed/?term=Hanigan%20IC%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed?term=2007%5Bpdat%5D+AND+johnston%5Bauthor%5D+AND+biomass&TransSchema=title&cmd=detailssearch

No effect level


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.


http://www.ncbi.nlm.nih.gov/pubmed/?term=Johnston%20FH%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed/?term=Bailie%20RS%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed/?term=Pilotto%20LS%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed/?term=Hanigan%20IC%5BAuthor%5D&cauthor=true&cauthor_uid=17854481

http://www.ncbi.nlm.nih.gov/pubmed?term=2007%5Bpdat%5D+AND+johnston%5Bauthor%5D+AND+biomass&TransSchema=title&cmd=detailssearch

California

• 9,000 separate wildfires

• >1,000,000 acres burned

San Diego

• Medi-Cal population

• San Diego firestorm

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PublicHealth

o 500,000 evacuated

o Mult iple school & road closings

P 1, ~QI lo-,tl ~ , COn<t,on W ...... ~ _,.._,. IINI••""" to< $0nslllw,GIO<IPI

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ZIP CODES

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9225,9

San Diego 2007 Wildfire Research Study: Collaboration with San Diego County, Michigan Tech Research Institute


3322

~~ ~ ~~ R!i

PublicHealth

-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



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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PublicHealth

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



2.0

0::: o::: 1.5 t

Asthma

Upper Respiratory

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Respiratory Symptoms Acute Bronchitis

'

II

I

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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 L__J L__J L__J

1-5 6-10 111- 1-5 '6-10 11-15 1-5 '6-10 11-15 1-5 6-10 11-15 1-5 6-10 11-15 1-5 6-10 11-15 1-5 6-10 11-15

~~ ~ ~~ R!i

PublicHealth

days

Visit Type

+ Emergency Presentations ¼ lnpatiient Hospitalizations

+ Outpatient Visits

Respiratory visits



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

~~ ~ ~~ R!i

PublicHealth

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



Asthma

2.5~------

2.0

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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

1-5 6-10 111-15 1-5 '6-10 11-15 1-5 '6-10 11-15 1-5 6-10 11-15 1-5 6-10 11-15 days

1-5 6-1 0 11 -1 5

~~ ~ ~~ R!i

PublicHealth

Visit Type

+ Emergency Presentations

¼ lnpatiient Hospitalizations

+ Outpatient Visits

Respiratory visits



l~ \!_ 11', ~ -· \ RR -~ ntJ %~ 0 ....i. N u)

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Center for H

ealthy Com

munities

Environmental H

ealth Investigations Branch

Respiratory visits, by age group

38

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,

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Center for H

ealthy Com

munities

Environmental H

ealth Investigations Branch

Respiratory visits, by age group

39

~~ ~ ~~ R!i

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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


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

40

~~ ~ ~~ R!i

PublicHealth


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



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

41

CARDIOVASCULAR EFFECTS & WILDFIRE SMOKE 2015 WILDFIRES

~~ ~ ~~ R!i

PublicHealth

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


4422

All-cause Cardiovascular

1.2-

1 .1 -

+ a:: 0::: 1 .0

0 .9-

0 .8-

'•i • ----Light Medium Dense

~ ~~ R!i PublicHealth

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.


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


4444

.. ,. ~---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

~~ ~ ~~ R!i

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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/


http://www.nixle.com/

https://www.airnow.gov/

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 ®@

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designed for fami ly

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internists,

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physicians, nu rse

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pulmonary spec ialists,

cardiologists, and

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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


https://www.epa.gov/pmcourse/continuing-education-particle-pollution-course

https://airnow.gov/index.php/air-quality-and

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PublicHealth

Acknowledgements The San Diego 2007 wildfires and Medi-Cal emergency department presentations,

inpatient hospitalizations, and outpatient visits Sumi Hoshiko, MPH


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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PublicHealth

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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PublicHealth

THANK YOU!

Sumi Hoshiko, MPH



[email protected]


4499

mailto:[email protected]

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