Hello, and welcome back for day two of our virtual fall summit. Today our focus is on climate change, its impact on occupational and environmental medicine. We have assembled a group of expert speakers to discuss the various routes of exposure we encounter in our environment. As occupational and environmental medicine specialists, we aim to manage not only the workforce but also the broader community and its population. We'll explore exposures related to lung health, environmental factors, and the effects of wildfires. Join us for a half day dedicated to understanding how climate change affects occupational and environmental medicine and what we do to address these challenges. It is now my distinct pleasure to introduce you to today's moderator, Dr. Alia Khan. Over to you, Dr. Khan. Thank you, Dr. Saito. Good morning and good afternoon, and welcome to day two of ACOM's virtual fall summit, Environmental Curriculum Climate Change. I am Dr. Alia Khan, and I am the Occupational and Environmental Medicine Residency Program Director at the University of California, Irvine. I am pleased to be moderating today's sessions. We have a full agenda with outstanding faculty who will address lead in pipes, our experience and a review of leaded pipedope in occupational groups, Libby-Amphibol disease, not-yet-grandfather's asbestosis, the East Palestine derailment, and changing climate, New York City haze, and wildfire smoke impacting workers' health in the urban metropolis. Our first speakers are Ms. Sheryl Rook and Dr. Kevin Hedges. Sheryl Rook is a registered nurse specializing in occupational health, safety, and environmental health. She holds specialist certifications in occupational health nursing from the Canadian Nurses Association and the American Board of Occupational Health Nurses. In addition, she holds certification in safety from the Association of Canadian Registered Safety Professionals and holds diplomas in both occupational health and safety and environmental health from McMaster University. Sheryl has worked as an occupational health nurse for the past 35 years. Her work experience includes the manufacturing and insurance sectors. For the past 25 years, she has worked for the occupational health clinics for Ontario workers. Sheryl Rook has been involved in many projects throughout her years with OHCOW, looking at individual workers with an interdisciplinary team to determine and characterize work-relatedness of occupational disease. Much of this work has also been carried out towards prevention of occupational disease as well as supporting advocates in compensation claims, as well as influencing policy to recognize occupational disease towards the acceptance of claims. Dr. Kevin Hedges obtained occupational hygiene certification in early 2000 as certified occupational hygienist and certified industrial hygienist, spent the first 10 years as a field services supervisor based in an Australian environmental health laboratory. He also co-authored on an Australian Institute of Occupational Hygienists position paper on lead. A site occupational hygienist and senior regulator with the Queensland Mines Inspectorate carried out regulatory oversight along with inspections and auditing of lead mining and processing operations in Queensland, Australia. For the past seven years, he has been employed with the occupational health clinics for the Ontario workers as an occupational hygienist. He is also past president and current board with Workplace Health Without Borders. Hello, everybody. My name's Kevin Hedges. And firstly, I just want to thank the American College of Occupational and Environmental Medicine for accepting our presentation. It's a really important issue, we feel, to present at the Virtual Force Summit. Firstly, I just want to say I've got nothing to disclose. The title of our talk is Lead in Pipes, Our Experience and a Review of Lead in Pipetote, Exposure and Health Risk in Occupational Groups. I've worked very closely with my colleague who's also going to present, Cheryl Rook, who's an occupational health nurse. Both Cheryl and I work for the occupational health clinics for Ontario workers. We've also worked in collaboration with UNIFOR, which is a Canadian general trade union. They were founded in 2013. And we also presented similar information at an inter-union conference earlier on in the week, where five different unions were represented. So we really want to get word out there and share this information as widely as we can, which is one of the reasons why we're presenting here through AECOM today. So basically, what we want to do is provide a background in the occupational health clinics for Ontario workers, including history and recent projects. We also want to provide an update on lead. What's the latest information with regard to health effects? We were approached by UNIFOR, national and local, to review lead risk management, specifically for lead exposure from thread sealant containing lead. What is the lead-based thread sealant and how is gas that has been exposed? What are the up-to-date known health effects from inorganic lead exposure? And how is lead exposure assessed, both for personal exposure and biological monitoring? And I specifically want to talk about biological monitoring of exposure for lead and the importance of biological monitoring exposure and different methods to assess previous short-term and chronic cumulative exposure. We also want to touch on the current regulations to see whether they offer an acceptable level of protection for all workers. And now I'm going to hand you over to Cheryl Rook. Hi. So just to give you a little bit of background with our clinics, back in 1980, the Steelworkers Local 1005 set up a committee to establish an occupational health centre for their membership. And they connected with a number of doctors at McMaster University who were part of their program in occupational health and safety and who had been working with the Ontario Federation of Labour with some of their health and safety training courses. And if you look in the top right-hand corner, you'll see the doctors there. One in particular, Dr. Ted Haynes, has been very involved. And through this interaction, Steelworkers Local 1005 hired some of these doctors and the first union-sponsored occupational health clinic in North America was established in 1981. Then in 1988, our Ontario Federation of Labour, with Ontario's Ministry of Labour, funded a three-year pilot project for two clinics, one in Hamilton and one in Toronto, Ontario. By the end of 1991, two further clinics were opened in Windsor and Sudbury, Ontario. Then in 1999, some groundwork began for a potential Sarnia clinic, which was officially up and running in 2003. Now we have seven clinics across Ontario, which includes a part-time clinic in Thunder Bay and our newest full-fledged clinic in Ottawa, Ontario. So a little bit about who we are and what we do. We're staffed by an interdisciplinary team of occupational health nurses, occupational hygienists, ergonomists, researchers, client service coordinators, and contracted occupational health physicians. And each clinic does essentially five forms of service. We have, number one, an inquiry service. So we handle questions from anyone in the community about health and safety. Number two, we have a medical diagnostic survey. So we see workers and take detailed medical and exposure histories. We review the literature and see if we can find a link between their disease and their exposures or injury exposures. Number three, we provide group services for workplace health and safety committees and groups of workers. Number four, we provide outreach and education to increase awareness of health and safety issues and promotion of prevention strategies. And number five, we provide a research service to investigate and report on illnesses and injuries. So again, we have an interdisciplinary team. We are funded by the Ministry of Labor, Immigration, Training, and Skills Development in our province. And we're part of Ontario's prevention services. So our funding comes from the premiums that employers pay to our Workplace Safety and Insurance Board, which then gets transferred to our various prevention system partners. And on our Board of Directors, the majority of the members are labor health and safety reps, not all of them, but the majority. We would encourage you to visit our OCAL website. We have lots of health and safety resources. And as well, we have a news hub where we post news articles on health and safety, both within Ontario and abroad. And also, I would just like to quickly review our mission. We essentially have three points. Number one, to protect workers from occupational disease injuries. Number two, to support them with the capacity to address their occupational health issues. And number three, to promote the social, mental, and physical well-being of workers. And we try to do this by providing a comprehensive, comprehensive, and comprehensive plan. And we try to do this by identifying the workplace factors that are contributing to their issues, by empowering workplace parties to make positive changes in their workplace, and by providing information and knowledge to help eliminate the work practices and the exposures that lead to occupational illnesses and injuries. So we also do a cluster work. We've got a number of projects that look at different exposures at a larger level. And if I just go back to the original slide here, this is around the McIntyre powder project. So for decades, miners were forced to inhale aluminum powder. It was aerosolized on purpose in the change rooms before they went underground. The idea was that it would coat the alveoli of the lungs and, you know, stop silicosis. But it never did that. And as a result, many, many, many workers were exposed to this aluminum powder. And Janice Martel put in a claim for her father's Parkinson's being a result of being exposed to McIntyre powder. It was denied. But then we did a lot of research. We had intake clinics. And recently, the ministry does now acknowledge that, and the WSIB acknowledges that McIntyre powder causes Parkinson's disease. So you see the Labour minister there providing an apology. We also, as part of the project, we took former miners down to McMaster. And we had their lead in bone measured using neutron activation analysis. And we showed that, you know, even after 40 years after being exposed, there was still a significant amount of aluminum in the bone. And in fact, the aluminum in the bone, the level was very similar to dialysis patients in the 1970s and 80s, where neurological degeneration was observed. Now to lead, you know, the advancements in technology has made it possible to research lead exposure down to very low levels. You know, lead, we've known lead has been risky for, you know, thousands of years. You know, a lead mine in Turkey about 6,500 BC is the oldest recording of a lead mine. Many products have had lead in them. I just, you know, even medicines and cosmetics. And there's a very good hyperlink that I provided there by Dr. Herbert Needleman. There's also old information that kind of, it's almost like a poem talking about the effects of lead, including jaundice, palsy, with shaving, or pale with keene but hollow eye. And you might want to look at this and think about how long lead's been around. And there's a very good hyperlink. There's a very good document here. I provided a hyperlink through the EPA that provides a historical perspective as well. So, you know, like I said, many components have lead, and now lead-based paint is an issue, especially with older health diseases. And, you know, one of the phrases, you know, in ancient times was crazy as a painter. So, you know, we know that there's many health effects from lead. However, a lot of the history of lead has been from lead poisoning, and what's not been well understood in the past is that every day exposed at low level lead also has health effects from chronic lead poisoning. And I just want to acknowledge, you know, the people that sort of, you know, the people that came and developed a lot of the science behind this, Dr. Alice Hamilton, and more recently, Dr. Herbert Needleman, who passed in 2017. And he looked at studies that followed children, and he was able to look at lead in their teeth, and he was also able to correlate the lead in teeth with reduced IQ. And in studies that followed, he determined lead poisoning had long-term implications for a child's attentiveness, behavior, and academic success. This is kind of just a snapshot of all of the different health effects. This is a pediatric doctor providing this on the web, but I think it kind of provides a pretty good snapshot that you could look at. There's a newspaper article here that goes back and looks at Detroit, you know, the really old houses with lead-based paint and lead in soil, and, you know, the high levels of blood lead for children. And there was also a study where they actually looked at higher mean childhood lead concentrations being associated with region-specific reductions in adult brain matter. It's quite an interesting study because they've been able to track the children, and then they've been able to show that there's a reduced capacity in the brain as a result of lead exposure. And this is just a graph showing what kind of levels we're talking about, all the way down to five micrograms per deciliter that they've been able to look at this for the Cincinnati study participants. So we know now this is actually, I think it's been a catalyst for a lot of momentum in lead. It's a toxicological profile for lead by the ATSDR. And there's a lot of information here around lead levels, typically less than 10 micrograms per deciliter. And they're even showing that, you know, lead, blood lead, less than five micrograms per deciliter, they're showing a number of different health effects, neurological, renal, cardio, hematological, immunological, reproductive, etc. So especially neurological effects in children, what the document has shown is that there's larger decrements in cognitive function when lead in blood increases from one to 10 micrograms per liter to deciliter compared to when lead in blood increases greater than 10 to 10 micrograms per deciliter, which is actually really showing that, you know, the importance of looking at very low levels and understanding the health effects at these low levels. Like I said, children have been studied, and even in adults with blood lead ranging from less than 10 to 15 micrograms per deciliter, there's been evidence of adverse health effects as well. Results of a few studies that have followed children to early adulthood show an association between child lead, blood, and behavioral and neurotomical changes in adults, suggesting a possible impact of exposure in childhood to adult outcomes. There's a number of different health effects, and like I said, many of the health effects are now shown at less than 10 micrograms per deciliter, which is quite concerning when you think about the regulations and where workers are required to be removed from lead risk jobs. So just the story here, the Unifor local approach, Sheryl actually, Sheryl Rook, about this issue regarding lead-exposed workers. So the historic inorganic lead exposure came from lead pipe, the lead-based pipe thread sealant, which is in a paste form, which can contaminate the skin and work clothing. Apart from worker exposure, the concern is also taking the lead contamination home and exposing family members. The company actually stopped using the material in 2020, but the material is still on older fittings, so there's a legacy issue, and especially when they take apart the fittings, they're also exposed, mainly from ingestion, just the contamination on the skin and the clothes. And there is a medical surveillance program which is voluntary. It hasn't actually been taken up very well. There hasn't been many workers that have had their lead and blood measured. Now, this is the actual material. It's massless metallic, and you'll see on the top right-hand corner, this is just a snapshot from the web. There's a little, the can opens, and there's a brush in the can where you can actually apply the, it's like a paste kind of material to the thread. And I guess the major concern is it's got 80.67% lead in it, and ringing different suppliers just over the phone, I found three suppliers here in Canada, you can actually get it over the shelf here, so it is still available. Somebody, even a home person can get it and use it at home. The safety alert was released through the Pipeline Contractors Association of Canada. We're still not sure how widely this is used, especially in the US as well. There is different ways to carry out monitoring. You can put a pump on somebody and measure what they're exposed to. But in this situation, exposure to lead is going to be primarily from handling it and primarily from ingestion. A lot of triggers to have a lead management program rely on airborne lead. But this is a case in point where that doesn't apply. It's more on ingestion. So really the lead in blood should be the trigger. So biological monitoring of exposure attempts to estimate the internal dose, which accounts for all routes of exposure. So when I was talking about lead in blood, that's really going to look at all routes of exposure, and it's the most prominent, best validated biomarker for lead exposure. But however, it's really a measure of recent exposure. So typically we think about a biological life of a month, but that will change depending on how much lead is exposed and how long the exposure has been there. There's also biomarkers of effect, and I've got some biomarkers of effect. So when the health effects are starting, including ALAD, ALA, but I guess we must consider ethical implications when we're going down that biological effect monitoring road. This is a paper that we came across, just a diagnostics strategy where you look at whole blood and you combine it with other parameters like ALA and coproporphyrin and your own NALD and zinc protoporphyrin. So like I said, lead in blood has a biological half-life of about a month. So really that's where X-ray fluorescence is very handy, to look at lead in the bone. So X-ray fluorescence has been used for decades in health studies, and a portable XRF is actually getting a little bit more attention. Although the X-ray fluorescence K-shell testing is the standard, and that's carried out at Mount Siloam at the moment. Neither X-ray fluorescence, K-shell or L-shell are available in Canada at the moment. But there have been studies where there's been extrapolation carried out. Look at lead concentrations in the tibial bone and, you know, versus accumulated blood lead based on the annual mean blood lead concentration in lead smelter. So you can look at the lead in bone. You can back calculate what the lead in blood was many years ago. Like I said, it is carried out at Mount Sinai, and this particular company in question do send workers down to Mount Sinai. It would be great if this testing was provided in Canada, and we are working with researchers to understand the instrumentation and whether K-shell or L-shell, preferably K-shell, can be used in Canada, you know, if L-shell testing is becoming more sensitive. There's one study that showed a correlation of 0.65 between the two different methods. So when the Ontario Ministry of Labour, Immigration, Training and Skills Development, you know, they inspected the site, they did issue an order around medical surveillance, and they also required workers to wear nitrile gloves and Tyvek suits, and blood lead monitoring has been carried out. However, even after it's been banned in 2020 by this particular company, it's still found on old fittings they take apart daily. So lead exposure by the skin and animal contact will still occur regularly, as indicated by white test and blood lead levels. So OCA, the Occupational Health Clinics for Ontario workers, are working closely with Unifor to share, you know, good practices and really alert workers to the health effects of blood lead levels below removal levels. We're just using the latest documentation. This is a very good table from NIOSH 2023 that does talk about, you know, what the different levels should be, and, you know, the California Department of Public Health recommends that if a blood lead is between 3.5 to 9 micrograms per deciliter, then there should be blood testing every three months. ACOM really uses 3.5 micrograms per deciliter as the benchmark as well, especially for women who are of childbearing capacity and planning to become pregnant. This is the range of results for this particular company, and I've highlighted all of the results greater than 5 micrograms per deciliter. These results are de-identified. They're pooled, so we don't know how many of them are women who are pregnant or childbearing potential, and even the result greater than 20 there, it's a removal level. We don't know if that worker was removed. ACOM actually does have a position, and they did provide a position back to OSHA, actually, on what they feel should be in the program, but we just want to make sure that everybody knows that the regulatory limit in Ontario isn't really set low enough, you know, to kind of manage adverse health effects, because they can occur below the MOL removal limit. They do have a removal limit of 20 micrograms per deciliter for two repeat measurements, and that's for general population, but then for women who are pregnant or childbearing potential, they have 10 micrograms per deciliter, and if you refer back to the health effects, we think that that's not low enough. The Australian Institute of Occupational Hygiene's position paper is more protective. It recommends 5 micrograms per deciliter. Nevertheless, there was kind of a big reduction in blood lead removal levels from 70 to 20 recently, and in 2020. However, before that, it's likely many would have exceeded the current removal limit. So, there is a likelihood that there is a body burden of lead stored in the bone from past exposures. So, adverse health effects can occur below the regulatory limits. It's really important we provide communication and training, especially for women who are childbearing age capacity, planning to become pregnant, and for this particular situation, washing machines have been provided in different centers. They're not being used that much, and with the wipe testing vehicles, they're still picking up a lot of lead contamination in the vehicles themselves, and so it's really important that they be made aware about what to do with regard to not, you know, taking the contaminated material home. So, you know, we just want to reinforce and advocate for a better clean in, clean out policy, and now I'm going to hand you back to Cheryl. Thank you. So, we have a range of current and future work that we're planning with this union. Currently, we're working on a lead booklet specific to the gas fetters' exposure and the dust that they're now experiencing, the lead dust, and once that's finished, hopefully later this year, it will be distributed by Unifor to gas fetters throughout the province of Ontario. We are collaborating with researchers both in Ontario and New York to try to get x-ray fluorescent scanning back in Ontario. Whether that's affordable or not, we're still looking into that. We want to raise awareness about the health effects from low-level exposure. We know with this group of workers, they had exposure when they were originally applying the product, and now the legacy product, when they're taking the joints apart, there's all kinds of lead dust. We want to reinforce the importance of clean in and clean out, especially with this legacy pipe fitting issue because of that dust. I just wanted to highlight a few of our WSIEC cases that have been allowed in Ontario related to lead exposure. So, let me just take a step back and explain that within our compensation system, we have three levels. There's an adjudication level. If a claim gets denied at that level, it then goes to the appeals level. If it gets denied at appeals, we have one further level for a worker's claim to be heard, and that's at WSIEC, the Workplace Safety and Insurance Appeals Tribunal. It's a quasi-legal tribunal. Just a recent search, taking a look for any allowed claims at that level, they're allowed publicly. They're anonymized decisions. We can see that there is an aggravation of a pre-existing schizophrenia case that was allowed at this highest level of appeal. There is a twisted small bowel case related to lead, and it has to do with the ion exchange with calcium and lead ions in the bowel. That was allowed. There was a claim for polycystic kidney disease, which was allowed in a deceased worker for the survivor. The next three decisions, the lead toxicity causing mental deterioration, mental loss, organic brain damage, the next one for lead poisoning, the next one for cognitive issues. I would expect that there are probably a lot of cases allowed at the lower levels of appeal, but for one reason or another, these particular cases ended up at the highest level of appeal and were allowed. There's a case for a lung cancer that was allowed and also a case for kidney disease that was allowed. With that, I would like to highlight, just in finale, the ATSDR, their toxicological profile for lead that came out in August of 2020. On page four, I want to highlight a statement that they say toxic effects of lead have been observed in every organ system that has been rigorously studied. Leaving you with that thought, I would like to thank you for your time and attention, and we'll now open the floor for questions. Hello, everyone. Thank you, Ms. Brooke and Dr. Hedges for your really interesting presentation. As a reminder for our audience, please post any questions that you have for our speakers into the Q&A box, and I'll be happy to pose them to our speakers. Just listening to your presentation on the latest on lead and the impact on these workers, even at low levels, it's quite sad to see these ongoing impacts after knowing how much we know about the impacts of lead. It really showed the benefit of working with various stakeholders, such as labor and community groups. For example, close to where I am, there was markedly elevated lead levels found in soil in a city, and local environmental justice groups partnered with our institution to investigate this. We noticed that it really impacted vulnerable communities disproportionately. Thank you for highlighting this. One of the questions we're getting from one of our audience members is towards the end of your presentation, Ms. Brooke, about have you had any claims for ALS? That's a good question. In our system, we can only see publicly the highest level of appeal, which is the WSIET, the Workplace Safety and Insurance Appeals Tribunal level. It is possible there may be cases that have been allowed at the adjudication or the appeals level, but we don't have access to those. Based on what I can see at WSIET, there's been none at the WSIET level on this most current search. Good question. Thank you. As I was listening to your presentation about the Medical Surveillance Program, I heard that there may be some challenges in having workers participate, or you're not getting much uptake in participation. Could you discuss your thoughts on that and why there may not be that much participation? I'm not sure if there's participation and what kind of barriers there may be and what can be done to address them. Do you want me to take that one on, Cheryl, or would you want to take it on? So, recently, we presented an inter-union conference at Niagara Falls, and we shared the same information through five different unions at this conference. And we kind of tried to promote the value of biological monitoring, looking at lead blood, and the importance of doing that. It is voluntary, yeah, and workers need to trust that the information is going to be used to help prevent exposure. So, it's really about, from our perspective, through the unions actually getting the workers on board to see that this is a really important thing to do and get buy-in from them. Just that historically, in our system, the employer bears the cost for Medical Surveillance Program. It's a little hard to hear you, Ms. Rook. In our province, lead is one of the 10 or 11 designated substances, and employers are required to bear the cost of the Medical Surveillance Programs. And because it's lawyer-driven, sometimes workers don't fully trust the program and prefer to go to their family doctor. And that's where some of the breakdown is occurring, to be able to get consistent care. Not all family doctors are aware of occupational health issues, etc. So, we're working with the union to try to improve that education for the workers in this particular group, to have them participate in the Medical Surveillance Program. Could you speak to, now that you spoke about the employer, what's been the employer's response to these elevated lead levels that is being found in these workers? I guess, if I could start, they did actually ban Masters Metallic back in 2020, and they did pull a team together, and they did offer medical surveillance. So, they did monitor the blood lead levels, which is a great start. And there's a lot of work done by the company now to try and understand it and communicate the risk. So, it's kind of work in progress. I do think they're taking responsibility. It's just a very difficult situation because these blood lead levels, many of them are below regulatory removal limits, and it really does go back to the internal responsibility system. And the only way that things are going to be improved is through good education and raising awareness around the risk from low-level exposure to lead. And I guess, if I just want to make one more point clear here, if we just look at airborne lead, that can be a trap because lead can enter the body in many different ways, including ingestion. And in this particular case, ingestion is the primary route of exposure. So, if we rely too much on airborne lead, then this could get missed. So, I just wanted to make that point as well. Over to you, Cheryl. I can't hear you. I think you summed it up beautifully. Thanks. Yeah, I think that's a great point to bring up, the route of exposure in terms of prevention. And you mentioned in your presentation about taking some of those measures with the workers, and there's still some challenges around that. So, could you speak to more about that? What kind of prevention measures have been provided to the workers, such as wipes and advice on smoking and showering before leaving? Do they have access to these? And as well as in one of your presentation slides, I believe you talked about workers being able to bring that lead home to their family members. And has that come up in conversations with the workers? Is there a role here for the occupational medicine team to discuss that from a larger community point? I think absolutely. And the presentation that we gave this inter-union conference tried to reinforce those issues. We're kind of third party to the company. This is through a union. So, we're just giving information from the union. It seems the company are trying to do the best they can with this information. That's my feeling. And it is a take-home issue, the contamination. It's a big deal because, as we all know, that children can be much more detrimentally affected from lead exposure than adults can. And it's something that we're going to keep working with Unifor and the unions on. And the bigger community, I guess, as Cheryl and I are presenting through AECOM, and I've just got to thank Cheryl for being the catalyst to make this happen. It's so important that we all share this information and work together and figure out a strategy. Thanks, Dr. Kang. Great. Thank you. And has there been any attempts to find a way to engineer out the exposure? Because no longer being used, but workers are still being exposed to the old sealant. Has that been looked into? I believe that they do wipe tests and they do a bait for vehicles. But there are a lot of areas throughout the operation where they're still finding lead contamination from these old fittings, the old sealant material, the legacy issues. We kind of recommend it to when they should really reinforce this clean in, clean out policy. Are there better measures that can be taken to stop the contaminated material going home through cover? And just the importance of white tests, both at surface and skin level, and reinforce the importance of those other kind of control measures. But like I said, we're kind of a third party here. We're kind of interviewing. We're trying to understand what control measures are there at the moment. I'd just add a piece to the previous question. I just wanted to mention that piece. Sorry, can you speak into the microphone again? I just I just wanted to add a piece to the previous question about the role for the OCMED team. We do have a doctor who has got a lot of expertise in lead. He's in the hospital right now. Otherwise, we would have asked him to join us. And he's been part of this. We may have an online group meeting with some of the pipe fitters in the future. Right now, our focus is on getting the booklet done, getting that out and seeing what sort of uptick there is from this particular community to initiate compensation claims. And then we'll go from there. And I just think if I can add, you know, this is a perfect example where the occupational medical folks and the occupational hygienists need to work really closely together, you know, because we're about prevention. But we need to rely on the occupational physicians to help guide this as well. Yeah, it's really great to see the work in an interdisciplinary format. And we definitely teach our trainees and our learners about the value of working with various disciplines, especially at OEM. And that's what really makes our field so unique is because we can, you know, learn a lot from each other and work together and have impact on community. I wanted to ask, so for the workers that you did notice these elevated lead levels, were there any clinical effects seen? We have not seen any of these workers yet. We're not at that stage. But that's going to be the next step. Once we have the booklet, it gets distributed. We're going to encourage because of workers across the province, we're going to encourage them to initiate form six as well, which is our first workers first report to initiate a compensation claim. And for workers who have denied claims, they'll come to us for sure. And they do have a few 12 very sick, sick people that will probably come to us before they initiate a compensation claim, but we just haven't seen them yet. So, no, go ahead. I would like to mention, we wanted to share this experience because we had the union consent to do so. But because it was a new lead exposure, we've seen many lead exposures, but this was a new lead exposure to us. And we were curious to know whether any of your listeners might know of state pipe fitter experiences with lead based thread sealant. We know it's across Ontario, and we were curious about whether there's any knowledge of that in any state pipe fitter groups. It's a great question. If anyone here can answer that, please put it into the chat window. I'm sure that would be helpful. So, Jill Rosenthal says she's not seen any claims about that. That is my understanding with the removal limits in the US, they're still quite high. But there's a lot of work being done now. And just a couple of really critical documents here, the ACOM position statement in the Journal of Occupational and Environmental Medicine, March 2023. I think all of the participants should, if they don't really know about it, go back and look at it. And also the Agency for Toxic Substances and Disease Registry toxicological profile for lead, August 2020, which was in my presentation. I'd suggest people go and read that profile as well, which I think has been a catalyst for a lot of this work. And that goes to my next question to you all. What do you think should be the trigger or the measure for implementing a lead control program? ACOM has supported lowering the action limit in the PEL, but wanted to hear your thoughts on what's going on in Ontario. Yeah, if I could just refer to the designated substances regulation, regulation in Ontario, you know, a risk assessment really has to be done where there's lead that's present, produced, processed, used, handled, or stored, at which a worker may be exposed to lead. And that's not just airborne lead. That also means lead in material where you can have contact and ingestion. And I think part of that risk assessment, it's really important to involve occupational hygienists to help with the risk assessment to figure out whether or not a lead management program should be put in place. I hope you can hear me all right, because somebody put in the chat that I keep sort of fading out at the end, so hopefully the volume's okay. But the trigger shouldn't just be based on airborne lead. It should, like the material itself, the amount in the material, and also, you know, the exposure, including exposure by ingestion. And very important, look at blood leads. Really, in this situation, as the primary indicator rather than the airborne lead. Thanks. Thank you. And is your organization a member organization of the American Occupational Environmental Clinics, AOEC? Yes, yes, we are. We have been, at least since I've been at the clinics for 25 years, our previous CEO used to be on their board of directors back in 1998, and then more recently, in 2015, one of our executive directors was on their board of directors. I think our information in terms of the staffing is a little out of date on their website, but we are still members, yes. Great. Well, thank you. I don't see any further questions in the Q&A box, but I thank you so much for, again, participating. Dr. Khan, sorry, can I just mention one more thing? I just wanted to take this opportunity, as being the past president of Workplace Health Without Borders and a current board member, we also have a healthcare working group with Workplace Health Without Borders, and it's a great interface between occupational hygienists and occupational physicians, so people on this call might want to check out our website, Workplace Health Without Borders, and consider joining that working group. It's free to join, and it's international, and the information is readily shared, so thanks very much. Thank you. Do you mind putting the website into the chat window so we have access to that? That would be great. Thank you for sharing that, and Ms. Rook, sorry, did you have any parting words? I just want to say thank you for your time and attention, and if anyone hears of similar experience in the U.S., we would love to know about it. Yes, it's great to collaborate and share best practices as well. Again, thank you so much, Ms. Rook and Dr. Hedges, and we will now move on to our second presentation of our fall summit. Next, Dr. Jamie Zunich will present Libby-Amphible Disease, Not Your Grandfather's Asbestosis. Dr. Zunich graduated as Doctor of Medicine and Surgery from the School of Medicine of the National University of Columbia in 1978. In 1983, he completed training in internal medicine and pulmonary medicine at the Central Military Hospital in Bogota. Dr. Zunich worked as an attending in the pulmonary medicine department of the Central Military Hospital in Bogota and was associate professor at the Nueva Granada Military University School of Medicine. Dr. Zunich completed residency training in occupational medicine at the Mount Sinai School of Medicine in 1996 and continued to work as an occupational medicine specialist at the Mount Sinai Irving J. Selikoff Center for Occupational Environmental Medicine until 2013. He then transferred to the Department of Occupational Medicine, Epidemiology, and Prevention at the Northwell Health in May 2015, where he is an attending physician and assistant professor. Dr. Zunich was a Director of Medical Standards for the New York State Workers' Compensation Board between 2010 and 2015. He was involved in the creation of the WTC Treatment and Monitoring Program at Mount Sinai and served as co-investigator for the Libby Amphibole Research Program. Hello, my name is Jamie Zunich. I am a physician at the Northwell Health Department of Occupational Medicine, Epidemiology, and Prevention, and I am here to present you on our experience with Libby Amphibole Disease. First, I have to say I have nothing to disclose. So, I'm going to present our experience in this small town, small community located in the northwest part of Montana. It's the town of Libby. It's a very beautiful town. It's called the City of Eagles, and you can see the main road with the beautiful mountains in the back, those gorgeous snow mountains, the river nearby. So, Libby was the house of, or nearby, there existed a vermiculite mine that operated since the 1920s, and it was bought by a different company in 1959 with full knowledge of asbestos contamination. The Libby mine produced more than 80 percent of the vermiculite worldwide. Vermiculite was used for isolation, was used for planting because it's a very good material for planting. The mine finally closed in 1990, in part or in great part due to the public awareness of the asbestos hazard, and there was a lawsuit. This map illustrates the location of the mine. It was very, very close to the Libby town up in the mountain. This is an aerial view of the mine, kindly provided by Dr. Brad Black, who's the physician in charge of the Center for Asbestos-Related Diseases in Libby, and this is another view of the mine. The vermiculite was an open mine. It was exploded up in the hill. It was brought down from the mountain to a plant where they kind of put together the ore. They crossed it around the river and emptied it to railroad carts that run on the other side of the river. From there, it was brought to the Libby town. There was a second station, and from there it was shipped all over the United States. The company provided the people in the town with free vermiculite. It was given as a present to the town. The baseball field was all covered in vermiculite. The people in the house used the town used vermiculite for insulation, for gardening, for potting plants, etc. This is a picture illustrating kids playing in the vermiculite dust. This is not actually from Libby. It's from Minneapolis, but it was very similar in Libby, is my understanding. This map illustrates where shipments from Libby were sent throughout the United States. You can see it was sent all over the United States. It is estimated that some 30 million homes in the United States have Libby amphibole. Here in New York, the World Trade Center insulation in the first 20 floors contained vermiculite, Libby vermiculite, as part of the insulation. The vermiculite rock at the mouth side are illustrated in this slide as compared to the Libby amphibole, which is a totally different stone. This vermiculite was contaminated with this fiber that we have been calling Libby amphibole. It is composed of 5% of tremolite, which is the only asbestos-regulated fiber in this amphibole fiber. It has other components of non-regulated asbestos fibers. Therefore, it will not be considered an asbestos fiber under the regulations of the United States. The fiber is an asbestiform fiber. It is an amphibole. There have been studies on the characteristics of the fiber that are illustrated in this slide. What is the brief medical history of Libby amphibole and the issues of the mine? As early as 1959, there was a report of an unusual number of cases of pulmonary fibrosis among the miners in the Libby amphibole. In 1984, Dr. Locke published an initial report in an expansion plan in Ohio. It was really the first report that we know, at least, was not produced in Libby, was produced outside of Libby. This was a report of workers experiencing unusual asbestos-related conditions in this expansion plan in Ohio. Mostly, what they noted was a high frequency of pleural effusions, bloody pleural effusions. In 1985 to 1987, there was a more formal study conducted by McDonald and later on by Amandus. They did find or reported high rates of asbestosis and cancer among miners. In 1990, Drs. Whitehouse and Dr. Black presented their observations on Libby amphibole. Whitehouse is a pulmonary physician who is located in a town that is more or less 100 to a little more miles away from Libby, but he was the closest or at least the trust pulmonary doctor who was in charge of examining these miners. He noticed an unusual number of pulmonary fibrosis among patients exposed or persons exposed to Libby amphibole. In 2003, the ATSDR commissioned a formal screening among the Libby population, not the workers, but the Libby population, and they found an 80% prevalence of pleural disease among the regular Libby population. Currently, like as early as September of this year, if you Google the counties with the highest adjusted death rates for asbestos, you find that the Libby, Lincoln County, which is a Libby, the county where Libby is located, has the highest rate of asbestosis deaths in the United States. What has been our experience on the health effects of Libby amphibole? Basically, basically, or the most intriguing finding that we found is what we call this laminar pleural thickening. Let me try to explain what is our observation. Usually, when we see asbestos patients, we are used to see these very, very big plaques in the pleura. This is a pleural thickening that calcified. This is a CT scan from a chrysotile exposed patient showing the regular asbestos thickening that we are used to seeing in these patients. In Libby, mostly what we see is this very, very thin layer of pleural thickening that goes around the lungs in a laminar type of distribution, and that's why we have called it laminar pleural thickening. This pleural thickening does progress. This is a film of this patient taken in 2010. I'll show you. This is a film taken in 2004, and you can see the very, very tiny, hardly recognizable laminar pleural thickening, especially in the right hemitorax. Six years after, you can see how this has progressed with what I would call a significant amount of pleural thickening with a compromise of the adjacent parenchyma. You see all this pleural thickening in the parenchyma of the lungs. One of the interesting issues of this laminar pleural thickening is that you see it in the lung windows in the CT scan, but you don't see it or it kind of disappears in the mediastinal windows, and this has been one of the problems recognizing this because usually radiologists and people tend to see pleural thickening in the mediastinal windows rather than in the lung windows. This is a patient that had a CAT scan. You can see the laminar pleural thickening in the basis of the lungs, and in the mediastinal windows, it practically disappears. Nevertheless, this was real. This is the pathology image of this patient. This patient had an abnormal nodule in the left lower lobe. He underwent a thoracoscopy, and here is the laminar pleural thickening with calcification. This is another view that shows the extent of the pleural thickening, and this is a pathology of this patient showing asbestos bodies in the airways of the patient. I had the opportunity to join a grant that was supported by ATSDR that was set up to examine the health consequences of livy-amphibol. We did several cohorts of patients. One is what we call the minus cohort. We examined 256 minors, all patients of the Center for Asbestos-Related Disease. We found that 87 percent had pleural thickening, of which 67 was a laminar pleural thickening. Only 19, or as much as 19, had irregular pleural abnormalities. The interesting thing is that when you see the pulmonary function as related to the type of asbestos abnormalities, there is a real interesting progression of disease as you circumscribe to laminar pleural thickening with parenchymal opacities. You see how the pulmonary functions worsen the more severe compromise, and always the laminar pleural thickening is worse than the circumscribed pleural thickening. We examined a second cohort, which was composed of volunteers who had left livy before the age of lung maturation and never returned to livy, or maybe returned only to be part of this screening program that I mentioned before. We call this the pulse cohort. We got to examine 198 volunteers. 59 percent were female, and we found 48 percent of them had developed pleural thickening, of which 50-50 were laminar and circumscribed. The interesting thing is that there was, again, a very clear relationship between compromise of pulmonary function and what we call the pleural score, which was a way to measure the severity of the pleural thickening. The higher the pleural score, the lower the total lung capacities. The higher the pleural score, the lower the diffusing capacity. And when we compared laminar pleural thickening versus circumscribed, we found that the laminar pleural thickening had much more effect on the pulmonary function in these volunteers. In addition to this unusual way of showing pleural thickening in these patients, this pleural response is characterized by a high frequency of very severe pleural pain that, in many, many cases, dominates the clinical picture and, in some cases, requires narcotic pain exclusively for pain management. The severity is advanced. In many, many cases, there is rounded-up electasis. And the other uncharacteristic finding is that this pleural thickening progresses in a very, very rapid progression. We used to see very, very slow progression in asbestos-related disease in the regular asbestos, whereas the Levy asbestos disease progresses very, very rapidly over a few years. And you can see as much increase of pleural fibrosis and loss of pulmonary function. There has been reported of an unusually elevated number of mesothelioma cases, and this was reported by the White House in 2008, both in workers and in individuals that live in the town of Levy. And it was, again, shown in a study that examined case fatality workers, a case fatality study in 203 workers, where they found a very high prevalence of death asbestos-related deaths in these patients. Levy cases have been reported outside of Levy. There are reports in Ohio, California, Florida, Minneapolis, and many, many states. So, definitely, it's a condition that is prevalent or should be prevalent throughout the United States. And we think it's a condition that is not recognized because of the uncharacteristic findings of this Levy and Fibol disease. Now, the other very interesting finding in this population is a very high incidence of autoimmune diseases in this patient. And this was realized very, very early in 2005 by clinical experience. And the doctors were finding that Levy people had a higher frequency of autoimmune diseases. They got in contact with Dr. Fao, who's an immunologist in Montana, and she did a study, just a regular study, measuring antinuclear antibodies in a population in Levy as compared to a population in Missoula, which is another town in Montana. And she found that the Levy people had a higher incidence or frequency of ANAs just as a regular screening. They did a second study where they compared by survey the amount of people that were diagnosed with several autoimmune diseases and compared it with expected numbers based on the medical literature. And you can see in this slide how much frequently these diseases were in the Levy population. In order to further study that, Dr. Fao and her group has done several studies that are really, really very, very interesting and I think are a seed for much more knowledge need in the consequences of asbestos disease. We compare the incidence of ANA antibodies among the Levy population compared to a cohort of exposed asbestos workers that were seen at the Mount Sinai Hospital, and you can see how much frequent is the frequency of ANA antibodies as compared to regular asbestos workers. From systemic autoimmunity, the researchers have moved to local autoimmunity at the plural cavity, and they looked into these mesothelial cell autoantibodies. And again, comparing the Levy population with a Montana population, they have found a higher frequency of these mesothelial cell autoantibodies in people in Levy as compared to people that don't reside in Levy. They found that people with these mesothelial cell autoantibodies have a much more frequency of radiographic abnormalities, and when we compare the presence of these antibodies in the Levy population, we found that those in Levy that had these antibodies had much more higher frequency of pleural thickening as compared to those, for example, in the regular asbestos workers, who even though had some mesothelial cell autoantibodies, very, very few had pleural thickening in the CT scans. They have found that these antibodies cause collagen deposition in the pleural cavity, and this has been shown both in vitro and in vivo in mice examinations. They have found that the Levy patients show a very, very high level of a variety of autoantibodies in the blood, and that these autoantibodies are related to the progressive lamellar pleural thickening as compared to other different types of manifestations. So, in summary, this is a very, very unusual manifestation of asbestos. We call asbestos-related disease. This would be an asbestiform fiber that has unusual clinical manifestations and unusual autoimmune manifestations, and we think there is room for much more study and learning in this population. I wanted to present my respects to Dr. Levine, who was the first PI of this grant. He passed during the first or second year of the grant, and I hope this presentation serves his memory, and I wanted to thank our collaborators in the Levy Clinic and in the different hospitals and institutions that were part of this grant that are shown in this slide. And with that, I'll be happy to entertain any questions you may have. I want to thank you, thank the ACOM for this opportunity and hope that this brings this different fiber to the realization of our audience and that we start really, really looking for Levy-Enfield disease whenever we see asbestos patients. Thank you so much. Thank you, Dr. Zinuc. wonderful presentation on Libby-Anfield disease and highlighting the key issue, this key issue in the community, but also beyond that, the community, something that we should all be aware of, including our primary care colleagues, Susan may come to them first. We do have a question to get us started in our Q&A box here. So there's a question that says, were the volunteers in the PALS study workers or just residents? Yeah, the PALS study, first, thank you so much for the opportunity to, you know, present with this panel of distinguished panelists and presenters, and thanks, Dr. Kahn, for your moderation. The PALS cohort was composed of individuals who left Libby before the age of long maturation. So they were born in Libby, they did their elementary and high school in Libby. We got it at, I think, 24 for boys and 25 years of age for girls. This, you know, these individuals have left, as I mentioned, have left the Libby town and only came maybe for, you know, the Christmas vacations or when they were required as part of the screening program. So they really, really were exposed only during the age of long maturation, and the purpose was to evaluate the effects of this amphibole fiber during that age of long maturation. So they were not workers. Okay. Okay. Thank you so much for clarifying that. I see one of our participants with their hand up, Richard Wagner, but if you could put your question into the question and answer box and I could pose that to our speaker, that would be great. In the meantime, we have another question. What level of environmental exposure would be associated with pleural disease? Should consumers be concerned? So I think the answer is consumers should be concerned. There isn't really, I mean, to my knowledge, there isn't really a study of levels, correlation of levels of exposure and pleural disease, but we know that people who use this amphibole fiber in their homes as insulation materials or materials for their gardens, they develop disease. So I would say there is, I mean, there's of course a latency time. There is an issue of probably there's a relationship between exposure and disease, but to my knowledge, I wouldn't be able to answer if there's an exact level, but I know there's environmental disease or disease as a result of environmental exposure, if that answers at least tangentially the question. Thank you. And you have the chart on the pulmonary function test findings in your slides. Do you have an explanation for the low DLCO in these patients with pleural thickening only? Yeah, it is a very good question and unfortunately I don't have a full answer. We think that this autoimmune component or inflammatory component is definitely playing a role in pleural disease, causing much more than what we just see in the CT scan manifestation. So one of the explanations we think is that there is either an immunological or an inflammatory component in the parenchyma that we don't see. And we know that imaging is not 100%. There has been reports in the literature with regular asbestos where negative imaging, people with negative imaging still have interstitial lung disease. So it could be a combination of either or, but that's an open question that should be answered for the research. Thank you. And we have another question here asking how prevalent is insulation material in current housing stock? Is there any data on distribution? I really don't have the answer for that. I showed that map that showed where libby amphibole was shipped throughout the United States. One of the issues that I mentioned in the presentation and really is one of the messages that I would like to leave after this presentation is that we think there's a lot of under-recognition of libby disease. So in terms of prevalence, I don't think we can answer that question. So sorry, but that's as much as I think I can say. Thank you. And could you discuss a little bit more about the clinical differences that are seen between the chrysotile asbestosis and libby amphibole? I know you mentioned that the libby amphibole is more aggressive or faster progression. Could you elaborate more on that? So yeah, I think I touched on some of the differences. The radiographic imaging is really, really striking. This presentation that we have called laminar product thickening is really, really, I would say very, very unique to libby, even though when you put your attention to that, we have found laminar product thickening in chrysotile exposed workers as well. The association of this plural thickening with associated symptoms, especially pain, difficulty breathing is kind of striking as well. The regular plural thickening that we are used to seeing asbestos workers is generally asymptomatic, is a finding of x-ray or any imaging, but patients generally do not complain of pain or difficulty breathing. The association of systemic disease, as I mentioned before, it would be another kind of unusual characteristic as compared to the regular asbestos, and finally, the progression. Some patients in libby really, really progress over the course of very, very few years, whereas in regular asbestos, chrysotile asbestos, we're used to see that progression over many, many years, if any progression. I think that kind of summarizes the big differences that, at least as per our experience, we have found. Okay. Thank you. Have you noticed any other types of pulmonary malignancies besides mesothelioma that have been associated with libby-amphible disease? The classical, yes, we know, but the people in libby have seen pulmonary cancers and mesotheliomas associated with asbestos the same. Meso is striking because they're so close to asbestos, but definitely lung cancers are much more frequent than mesotheliomas. Okay. Thank you. I'm just curious about what's the current status of this site? I understand it's a Superfund site now. What measures have been taken to clean up the contamination, both in that area where the workers were and the mining, and then also in the town itself? Yeah, that's a very, very good question. As you mentioned, libby was declared a Superfund site. The government agencies really, really undertook a very, very comprehensive cleanup process. I know people were taken out of their homes and the homes were thoroughly, thoroughly cleaned as much as possible. They set up very, very low and very conscious levels of what they would allow as a permissible exposure limit after cleanup process. My understanding is that the town has been mostly cleaned at this time, the mine site is closed. They still have found, which is interesting, asbestos fibers in the bark of the trees that are near the mountains, in the mountains near the mine. There is still contamination in the environment or potential contamination in the environment. One of the industries in Libby was a logging industry, and that has died because of the asbestos contamination. The cleanup process in the town is commendable. I think the government agencies did a very, very good job at cleaning the town. Interesting. Just as an anecdote, the other week in a local town over from me, there was a military hangar that caught on fire. They found asbestos fibers in the air. They're working on mitigating and doing cleanup in that area, and there's been a lot of concern to the immediate area. They had to close the schools down in the local park, so it keeps on coming in various areas. There is a question in the chat asking if you've seen any cancers of the GI tract. Yeah, I wouldn't be able to answer that. Our experience with Libby has been mostly, or my experience mostly, has related to the participation in this grant that I was able to participate. I really wouldn't be able to answer that. I'll pass the question to the doctors in Libby to see if they're seeing any increase in cancers in the GI tract. I really cannot say that, I'm sorry. And there is a comment saying that Libby is no longer a Superfund site, logging died because of low timber sales, not asbestos. Yeah, Libby is no longer a Superfund site, I agree. And I mentioned that the cleanup was very, very, very thorough. So yeah, I would say yes, it's no longer a Superfund site. And I was curious, how has the impact of this disease affected the local community, even beyond health, but also from the social and the economic aspects? Yeah. Do you comment on that? I'm not an expert in that tangentially, but definitely there was a big impact in the beginning. The town was very, very affected. Many, many businesses closed, many people moved away. There has been several studies published on the psychosocial consequences of Libby. They were run through the car cleaning center for asbestos disease. And they did find psychological repercussions among the population in Libby. Most of them, as time goes by, people regroup and they come back from the initial effects. My understanding is Libby is a town that is trying to regrow again and go back to what it was before. But definitely there was a big psychosocial impact of this disaster. And could you also speak to, in relation to that, what lessons can other communities or industries learn from the experiences in Libby regarding asbestos exposure and contamination? So several lessons. One is the eternal lesson of the companies knowing about hazards and not telling the people around or their workers of the hazards of exposure. And this is the history of occupational medicine. We've seen it at many, many different levels. And here you have a company that knew that there was contamination from the 1950s and nevertheless continued to explode the mine until the 1990s. I know there was a big involvement of the community in the process of establishing the cleanup efforts. And I think that was very, very well conducted from the government agencies and the community really responded in a positive way to the cleanup efforts. As always, you see the pros and the cons. There's people who understand the effect. There's people who are either deniers or not believers. And that also happened in Libby. There was division in town and people who believed and people who didn't believe in these situations. Still, there's some divisions, is my understanding, divisions in town of the believers and the nonbelievers. So all of those is what we see all the time when it's one of these disasters. So there is a, I think it's a comment, but it's in the question and answer box. Libby is coming back. The population is relatively stable. There is a new wave of people moving to Libby and nearby Troy. People are trying to put this behind them because of the bad rep it gave the area across the state and nationally. I've lived in western Montana for over 40 years and I regularly see patients from Libby. It's one of our participants. Yeah, I would agree with that. I think people is coming back. People is really, really showing the resiliency and Libby is growing again now that the cleanup process has been completed. Yes. But it's a lesson we have to learn. And I think the disease is still, you know, we know it takes a long time. We know that the people who were exposed are still affected with the disease. And, you know, the one of the purpose of this presentation is really, really to have people aware of different manifestations of asbestos and asbestiform fibers and really, really, you know, bring to our audience's attention of these unusual manifestations. And if you see something, you know, just bear in mind that Libby was Libby and people was exported throughout the United States and it could be, you know, a manifestation of this disease. And could you also touch upon how has the situation in Libby influenced regulations and practices in the region and other regions? I my understanding, not too much. One of the one of the issues is, is that, as I mentioned before, the Libby people is not is not a regulated asbestos fiber and it hasn't been accepted as a regulated asbestos fibers. And and it should definitely open the possibility that there are asbestiform fibers that even though are not regulated, are still harmful, harmful to human health. I think the example of the of the of the of the Libby and people of the Libby town cleanup process is, you know, where community was involved, where there was scientific evidence put together to try to come with a to to a very to a an exposure level that was accepted and, you know, considered sufficient to for the cleanup efforts is is something commendable and probably should be replicated in cases that it happens in the future. And maybe those are lessons to be learned. Right. Thank you. And I don't see any other questions, but I just to kind of round out, in your opinion, what do you think is the most important message from your presentation to the general occupational medicine professional? I think there are several, one is, as I mentioned before, you know, we have to remember that asbestos still exists, you know, everybody thinks asbestos is gone and you just mentioned that, you know, this fire that happened near your town where so so asbestos is there is a very, very strong fiber and and it it really, really, you know, is is there and can stay and persist for many, many years. And we have to realize that there are known as non-recognized asbestos fibers that are harmful. Also, we know that there is asbestos fibers in different places in the United States. Nevada has some asbestos fibers and there are some seeds that are trying to look into the possible effects of these asbestos fibers in causing human human health effects. So so those would be the messages that I would I would think are important to learn. Great, thank you so much for those important reminders. And thank you again for your time during this question and answer and for your presentation. It was very valuable. And for everyone listening, we're going to be taking a break now. So this is a great opportunity to stretch, get some fresh air, bio break, and then we'll be restarting promptly at two thirty p.m. Eastern time. So we'll see you then. Thank you, everybody. Thank you. Thanks. Thanks. Thank you. The second half of our day will begin with Dr. Santos, Dr. Trangle and Ms. Teresa Einhardt presenting on the East Palestine derailment. Dr. Kevin Trangle is a physician board certified in occupational environmental medicine, internal medicine and preventive medicine and board eligible in addiction medicine. He is an active member of the transportation section of ACOM and has been a medical director for a railroad. His professional knowledge encompasses FMCSA and FRA regulations and recommendations. Dr. Trangle has established protocols and procedures to protect those technicians and professionals who may be exposed to various chemicals, IQ concerns, infectious diseases, environmental exposures, herbicides and pesticides, nanotechnology, disaster planning and potential adverse effects. His clinical orthopedic experience includes working as an emergency room physician and having care for patients while at University Orthopedics in Ohio City Orthopedics. Dr. Susan L. Santos is an internationally recognized expert in risk communication with over 35 years of experience in developing and facilitating risk communication training and developing materials in support of executing risk communication and outreach plans for a wide range of environmental and occupational risk and health issues. She is the founder and principal of Focus Group, a consultancy specializing in risk communication, health and environmental management. For over 20 years, Dr. Santos served as director of education and risk communication for the VA's War Related Illness and Injury Study Center in East Orange, New Jersey, where she developed training for providers on a wide range of deployment and occupational exposure issues. She has served as a member of several NASEM committees and the Board of Population Health and Public Health Practice. She is widely published in the field of risk communication. Dr. Santos has a doctorate degree in risk communication and public policy from Northeastern University, a master's degree in public health as well, and environmental engineering from Tufts University and a bachelor's in chemistry from Boston College. Ms. Inhert serves as a bureau chief for public health emergency preparedness and response for the Department of Health Services. The bureau is responsible for program oversight in emergency planning activities for tribes, county public health and health care partners in the state. Ms. Inhert is responsible for conducting a broad scope of operational and or program-specific analysis of policies, procedures and operations for the purpose of implementing statewide plans. Additionally, she serves as a health lead within the state emergency operations center. Ms. Inhert has been with the Department of Health Services for 18 years and has a master's degree in management. Hello, my name is Dr. Kevin Trangle, many of you I know. I'm here to talk about one aspect of the East Palestine derailment. So my goal today is really to talk about the incident itself, somewhat a little bit about my background, my background in the railroad industry and how I got involved, my background in the chemical exposure and catastrophe business and how I got involved, and then talk about actually what we as an individual organization and also as individuals from AECOM put together a program for the trackmen that work there. And I'm going to talk about those details and what it means and how it's going to work and eventually what is the path forward. This is my background, as you see here, I have nothing to disclose in terms of financial conflicts, any other involvement beyond what I've just said right now. And then we're going to end up talking about this incident. So as you've probably heard from other people, but if not, you'll hear it right now, there have been over one and a half million pounds of chemicals that were involved in this multi dozens of car derailment that occurred in East Palestine in Ohio. These are the chemicals that were involved. These numbers are put together by the manifest lists that were given to the both the union as well as to the management that had them there. So my background as an occupational environmental doctor is similar to many of your backgrounds. I've been involved in this for a long time. I've looked at other types of exposures, whether it's from tankers, from railroad cars, from semi trucks, from silos that have ruptured, from factories that have exploded. I've been involved in this and because of that, I got involved in a common, in particular, environmental committee. I've been lucky enough to work with such people as Kathy Fagan, who runs up the committee, as well as Manny Barangi, who is the co-chair. We also have involved individuals that were involved in this project, such as Mark Welkenfeld and Mason Harrell. All these people are very helpful in putting together a program that we thought would meet the needs of the instance of what happened here. These people were involved in the incident, the Trackmen, which there were, as I stated, about a hundred of them altogether. Ten of them may have been union, they don't know the exact number, but they were not union, may have been management, but they were still looking into this last communication I had. The genesis of this was that the Trackmen were working around, and I've talked to several of them, during their programs and cleanup and trying to figure out how to best handle the debris. They were walking around dressed just like this, not having hazmat, not having any particular supplied air, not having any skin protection, and they related several stories where the EPA people came by dressed in hazmat suits, tie-back, protection from the environment, as well as supplied air. They would take off their helmets and tell them everything was okay, put their helmets on and go away. These are actually areas where in some of the cases, there was dead fish that were around in nearby periphery. Some of the animals apparently had succumbed to the chemicals. No people, thank God. So when this happened, when the workers realized they were exposed to chemicals, when they realized they did not probably have the appropriate effective protective gear, and when they were told that at some point in time, they were working in potential human carcinogens, such as vinyl chloride, they were concerned. And the fact they did not have faith at that point in time in the state and in the federal agencies, they turned to the union management, and they turned to the union, tried to go out and recruit people to do this, and they turned to us. We're really the only recognized body, Occupational Environmental Medicine Group, our organization, that does this sort of thing. So we were asked to piece together a program that would look at the various chemicals involved, look at testing each of the chemicals in terms of what they did, their short and long-term effects, and then put together a monitoring program similar to 9-11, but clearly in a much smaller way of doing it. There are short and long-term reactions, and in fact, the way we did it was pretty uniform for each of the seven chemicals. The people involved in this, as I mentioned, were myself, Dr. Manny Berenji, as well as Dr. Mark Wilkenfield, and Dr. Mason Hero. We all took part in this. We all helped put together a program. There are other people involved that we had discussions and consultations with, including Dr. Fagan, among others. And together, I think we put together a program such as a mini-model for 9-11. The purpose is just as you see here. We wanted to make sure we were comprehensive. We wanted to make sure we took into account all of the potential risk factors. We also wanted, ultimately, to educate the workers because they are asking what should be done. We also wanted to put together, preferably, a good baseline database for class members. In other words, we wanted to do research and be able, at some point in time, to publish the information. I'll talk more about that in a few minutes. The people that were involved worked there. They were involved there. They did everything in terms of cleanup, and they were there. Some are still there, actually. So how do we set this up? Keeping in mind, we wanted to look at a variety of different things to make sure we took them into account when we set up the medical monitoring program. We needed to look at the different types of chemicals involved. We did that. I showed the list with you. We wanted to look also at the potential routes of exposure, skin, respiratory. Nobody was drinking that stuff, so that was not one of the potential ways. We also tried to get a better handle on that. And we will try to get a better handle in the future on the duration, frequency, who worked longer, and what parts of the exposure, and who may need more testing than others. The protective personal equipment, in general, was not there, but we took account of that, meaning we knew there was exposure. Ultimately, we wanted to provide the workers with some scientific basis for what kinds of monitoring programs we're going to do, and a scientific basis for what could happen in the future, because they all have the questions. Then we would have to educate them on this. So that was the goal of what we set out to do. Each of the chemicals were handled pretty much in the same way of the seven chemicals. We had a short section in the medical monitoring program where we looked at the chemical itself, what is the type of chemical, was it an organic compound, was it a vinyl chloride, was it something else, and what is the potential exposure, the routes of exposure, et cetera. We then looked at the short-term effects and the long-term effects, and then how you can test for those. Testing is different, of course, if it's a short-term effect. If you have a volatile organic compound, it's not going to last around for days or weeks, maybe days, but not certainly beyond that. We also then listed the potential short- and long-term effects in terms of pulmonary disease, skin disease, cancer, that sort of thing. There's a section in each of the chemicals on protective equipment and at what levels, what needed what type of protection, theoretically. Clearly, that's not a curve, but we thought it would be useful at least to have as a general construct how to do this. We then went on also to make sure that for each of the chemicals, each one, we looked at medical history, physical examination, blood tests that were needed, urine collections, in some cases, pulmonary functions, if it was something we thought would have a respiratory effect, reproductive health, and skin examinations. In some cases, we looked at what types of tests should be done. This is not the same for all the chemicals. Some may need this, some may not. For example, angiosarcoma clearly is a primary concern for people with onochloridae exposure, but not for every chemical. We basically looked at this and potential exposures and put together a pretty comprehensive monitoring program for each of the chemicals. When that was done, we sort of amalgamated each of the chemicals into one examination. In other words, we're not doing seven examinations on some chemicals. We're doing one examination on the individual exposed initially, and then we're going to do follow-up examinations at some point in time in the future. The frequency and the duration of how long we do that depended upon the exposure duration and the types of chemicals. We put together at the end of the day an initial examination and a follow-up medical monitoring program, highly dependent upon to what they were exposed, as you see here. The issues that we had to consider when we did this was looking at, obviously, the multiple different chemicals and the multiple different toxicities. I told you kind of how we structured this to take account of that. We looked at the routes of absorption, skin or inhalation, and we looked also clearly at the protective PPE provided, because that would tell us if they did or did not have exposure and how long they needed to be followed up. Every one of us thought that training education was important and an explanation to workers of what their potential future holds was important. So this is hopefully a model that we can look at in general that will put together what we think is needed, not only for the East Palestine, but we as an organization, or at least we as environmental physicians in this organization, can propose for any particular type of catastrophic spill or exposure to chemicals that occurs in this country. Where do we go from here? In terms of the railroad itself, Norfolk Southern and the trackmen, there has been discussions in which I've been involved, where the union has been involved, the union's representation has been involved, OSHA has been involved, and the actual railroad has been involved. The railroad had a proposal initially to have a one-time payment and have them work with the family doctors. I don't think that's really feasible. I don't think anybody in the group felt it was feasible. We need to have specialists. I'm trying to let them know that there is a specialty that knows how to do environmental medicine and that clearly was accepted by the trackmen, and I don't think the other option will be on the table. So we will be doing a medical monitoring program of some sort as part of the OSHA consent degree that Norfolk Southern signed. The exact nature of that is still being discussed, but ultimately that will be done. It will be done for a long period of time to make sure that people are followed along enough time that the latency is taken into account, such as angiosarcoma, and we can look at the potential developing of issues at that point. Where do we go from there? We're just talking about this point in time, one exposure, but it's my hope we can put together a rapid response team of medical specialists that have environmental training, which is our group, and we will hold ourselves out as experts to the community, meaning the U.S., that when this thing happens again, they can rely upon some of the best trained people in the country to give them professional advice on how to handle the workers and how to handle the people that were involved in a particular spill or a particular catastrophic incident. Just as an interest for you, I have been contacted by the Israeli Red Cross because although they have a medical team that does nuclear chemical biological radiation response, as we do in this country in each of our armed forces, they also do not really have set up this sort of rapid response group to handle what is anticipated to be a barrage of missiles and chemical spills from tankers being hit, trains, even ships in storage silos. So I think whether we do this as individuals who have already come to me and offered to work with me to set up and assist Israel in doing this kind of program, or whether we as an organization decide to do this, it is an opportunity for the future, an opportunity to increase the prestige and credibility of our organization. So where we go forth from here, we go forth with the workers in Norfolk Southern to make sure they're protected. We go forth with U.S. in terms of putting together an organization and a particular project that can handle the needs of this country when these things crop up, which they do and will, and something that will enhance our reputation and make our organization more relevant, and maybe even be a guiding light to some other people in the world. Thank you very much. Hello, I'm Teresa Ehnert with the Arizona Department of Health Services. I'm pleased to be part of this. It's a very educated and experienced group of people to talk about things that happen that connect public health when there's an environmental incident. Today, I hope to be able to provide an overview of a response that was here in Pima County, Tucson, Arizona, with a hazmat response, not as big as the one that you just heard about, but similarly difficult to connect the dots with. Our interagency response, incident command system basics for public health, and public health actions during a hazmat response, and then some takeaways. And I have nothing to disclose. Around 2 p.m. on Tuesday, February 14, a truck carrying liquid nitric acid crashed on Interstate 10 in Tucson, Arizona. The driver was killed, and the accident resulted in a chemical leak. The first person on scene was a commuting Border Patrol agent, and he took the initial steps to block some of the traffic. Anybody that's been in Arizona and traveled on that freeway knows there's not a lot of room on either side. It's two lanes. It's just two lanes, and so it was very difficult. So then the units arrived from Arizona Department of Public Safety, Tucson Fire Department, where unified command was established. A very different kind of incident command approach when it's on the interstate versus in the city. So again, it was a little bit of a challenge with communication and radios to get everybody connected initially. The Arizona Department of Public Safety hazardous response unit in Tucson and many others that you can see on the screen here coordinated their efforts to mitigate the incident and evacuate a perimeter around the area. In a few minutes, I'll go into what we do at the state health level and how we connect with local public health, who is our boots on the ground when coming up with clinical guidance for healthcare institutions and really what will be used in their press release for the public. So this was closed in both directions between some very busy roads, and it remained closed until 315, two days later. So that was a really big deal and what kind of scared the public. And then many of you know that would deal with incidents like this that you also have to deal with the worried well. So unified command worked with the Pima County Office of Emergency Management to broadcast shelter in place, messaging to individuals within the established perimeter. And this, what you see on this picture is really what it looked like for a very, very long distance, people could see this yellow and red smoke. So the Pima County Communications Office, the Health Department, our Department of Public Safety media outlets and partner agencies, all disseminated messages to the public. And when there is a situation such as this, the coordination of the message is so key and you'll hear from Dr. Santos on some of those nuances. Our shelter in place protective actions were issued throughout the response. Pima County created a web page about this acid spill. Numerous county departments, including Health, Department of Environmental Quality, Transportation, Emergency Management, all answered calls from the community. We here at the state did as well, where this occurred is about two hours from Central, hour and a half or two from Central Phoenix. But many people commute to that area and back. So there was a lot of questions. So the alerts were posted on our statewide Arizona Emergency Information Network, AZEIN. The nitric acid was contained to the median and a steady flow of these earth moving equipment delivered dirt. And because of the off-gassing that occurred with where this spill and the fire and debris was, I know it just is kind of awe of like, oh my gosh, that's a lot of trucks. But the dirt that was needed to stop, to cover this area and stop the off-gassing was quite a coordinated effort. So it covered the contaminated area while the crews continued to mitigate the active release. Incident Command, those that are familiar, it's a standardized approach to the command control and coordination of emergency response, providing a common hierarchy within which responders from multiple agencies can be effective. It's really where we all kind of speak the same language. It was initially developed to address problems of interagency responses to wildfires in California and Arizona, but is now a component of the National Incident Management System in the U.S., where it evolved into use in all hazard situations ranging from active shootings to hazmat scenes. Here's just a quick look of how the flow of information and resource requests for state and local emergency response in our state starts with our Division of Emergency Management and Military Affairs down to the Department of Health. We have local emergency management, local public health, hospital and health care, law enforcement, fire department, and EMS. And I will say that in a lot of these areas, there are many long-term care and skilled nursing that have to be communicated frequently about their HVAC. Within our health emergency operations center, we have the very standard approach, the operations, planning, logistics, and finance. So I won't read what each of these is about. But when we hear of a situation, we pull the policy team, our health director, and other key staff from our executive team to talk about how we're going to intersect with the local health department and provide assistance in health care response. Just a little bit more, again, around the operations section, it's kind of called the sexy side of response where a lot of the initial work happens. They conduct human and or animal case surveillance. They characterize public health, threat, environmental hazard, disease, et cetera, disseminated the data internally and to stakeholders. They handle all of the media, developing public messaging, overseeing risk communication, and really the resource tracking with hospitals, urgent care, and other facilities. We also utilize poison control here in our state quite extensively. The spill was concentrated nitric acid. That's a liquid. So unless an individual touches this or were in contact with a mist from the immediate release, their risk of exposure was low. But of course, people still thinking as they drove through on the other side of the freeway that they were exposed and possibly contaminated with this. That contact with the liquid or mist can cause immediate irritation of eyes, mouth, throat, or nose and skin because nitric acid is highly soluble, dissolves in sweat on the skin or mucus membranes. And I am not an MD or a medical expert, but we have a lot of medical folks on staff, our chief medical officer and our medical director for our Bureau of Public Health Emergency Preparedness. The nitric oxide, slightly water soluble, irritating gas that does not commonly cause immediate irritation, but prolonged exposure can. Individuals were instructed if they breathe in the nitrogen dioxide gas for more than 15 minutes, they should seek a medical evaluation. And individuals living or working within a mile of the exposure who sheltered in place and are having respiratory symptoms were advised to seek medical evaluation. And same with those who drove through or passed. And I will say that the Pima County Health Department and the health director, they jumped right on getting the hazmat spill clinical guidance to all the healthcare institutions, not only in their area, but was put out through a health alert network throughout the state. Our logistics section is exactly what it is. It says they get the stuff, the supplies, the space, everything that is needed. They also provide geographic information system and they work with our HEOC, our health emergency operations center manager, and division of public health licensing to identify the facilities near the incident. And the activation of our HEOC, if required, comes really from the actual policy group. Our health alert network and notifications to providers. And I will say that many states operate from this same framework when there is a response, environmental or other, to pull together their partners and how they can assist and provide resources as necessary. A big thing for us is assessing impacts to healthcare facilities and other licensed entities. And so I will talk just real briefly about the GIS mapping that we do here in Arizona when there is an incident. As you can see right here, we go on concentric circle on our maps and we go out 5, 10, 15, 20 miles. So as you can see in the initial area, not too many licensed facilities. And then we go out just a little bit more within 10-mile radius. It continues to grow quite exponentially. And then the list of potential facilities within that 20-mile, 15 to 10-mile range, it's just really almost unmanageable when you take a quick look at how are you going to message to each of them to see do they need help, do they need assistance. At the end of that, here's the kind of summation of what we discovered. As you can see, the number of licensed entities that either have inpatient, they do outpatient, we had hospice, sober living homes, assisted living, outpatient treatment, et cetera. It was a lot of work to connect with local public health to ensure a consistent message to all of these facilities to see if they needed any assistance. And our takeaways. The nitric acid spill brought together agencies from across jurisdictions. They partnered in response to the incident priorities, which are life safety, the incident stabilization, and property conservation. The response was technical in nature, however, and no known injuries or direct effects to the public or responders were reported. As I mentioned in the very beginning, there was a death. The driver of that truck did expire. No incident response is ever perfect. The lessons learned and reinforced that agencies and partners continue to review and revise their internal procedures. I'll say that after every event and situation, there's an after action report. It gives us an opportunity to see what all the strengths were, but more importantly, what we can continue to do better. Almost always, there's communication, being able to talk, use the right radios, the right communication methodology, and really how are we going to message to the public that everything is okay, but if they are feeling ill, this is what they need to do. Again, if you have any questions, we're going to be addressing that. I just want to thank you again for the opportunity to talk briefly about the public health incident management system, what we do here at the state level to coordinate with our local health, tribes, and healthcare system partners that are in the middle of an emergent event. Thank you very much. All right. Well, thank you for having me. It's a pleasure to be here. I think it's interesting to follow up on what Teresa said about the importance of communication. Typically, we think about communication as being the last thing we need to do. One of the messages I'd like to leave you with today, I hope, is the importance of thinking about communication from the very beginning and how important that is. The views that I'm expressing today and the information on my own opinion, and I have nothing to disclose. I think it's appropriate to start off with a definition. I want to use the definition of risk communication that comes from the National Academy of Sciences, really the National Research Council back in 1989, but really to stress, first of all, that risk communication is a science-based discipline. There's many, many, many years of research and experience that shows what works and what doesn't work. Hopefully, I'll share a few of those things with you. In terms of a definition, I've called out two important pieces of it to me that are the most important pieces of that definition. The first is that it's an interactive process of exchange of information and also opinions among individuals, groups, and institutions. Teresa had that slide about all those different groups and all those stakeholders and all the agencies that are communicating. That process has to go back and forth. It's not just one source, one receiver, one channel. There are also multiple messages about the nature of a risk. Who's at risk? To what? For how long? Even though we may think there's not a risk, others may frame it differently. Risk communication is about the nature of the risk and messages that express what I refer to as health risk management. What are you going to do about it? That's really the information about what you're doing to control or manage the risk. Sometimes in risk communication in disputes, it's often because people are concerned that you're not doing enough about what they perceive as a risk. It has to be an integral part of emergency preparedness and response. In practice, what does this mean? It means that most likely for many occupational and environmental risks, even those that are not a disaster, we may have a situation where there's lots of concern. We could have a situation where there's not much trust either in the entity that's seemingly responsible for the risk or asked to manage it. There could be, and usually is, lots of uncertainty. Then I have that word expert in quotes because there are many experts, and it will really be experts in the eye of the beholder in terms of who your stakeholders trust. I think when we think about the East Palestine train derailment and many of the disasters that many of you may end up talking about or thinking about responding to, they have all those characteristics. Risk communication becomes an extremely important paradigm to use. Let me give you some of the takeaways because we have such a short period of time today. I've already said that disasters typically have this low trust and high concern, and so we need to be communicating even in the absence of complete information. Many times, organizations don't want to communicate because they're not quite sure what the chemicals are in case of East Palestine or who may be at risk or for how long. Those people hesitate to communicate. In fact, there's a message that can be communicated even during that time. We also know that information is typically lacking at the beginning and then will change, and how rapid a change depends. I think about things that I've been involved in like 9-11 or the BP spill or a number of different disasters where what is said at the very beginning will change over time. We need to be able to think about how we're framing that for people so that we don't lose trust or people think that we don't really know what we're talking about and start to go to different stakeholders and sources, particularly the internet. People like to have instant access to information. There was just a truck spill last night in Massachusetts on a major highway, and you've got the people with their cell phones already taking the pictures of the plumes and the spills and the responders. All that gets out there before incident command has maybe even been invoked. People want to know what to do and what not to do, and then most importantly, spokespersons have to be, yes, knowledgeable, but also trustworthy, and they should ideally have authority as well. I love this slide about communication through the stages of a crisis because even if you don't know what the next crisis is that you're involved in, this gives you a great template, and it was prepared by the CDC back in 2002, I think, in many ways in response to the 9-11 incident. It tells you what you should be doing before crises occur all the way through to the evaluation. I should say this is more like a circle. Pre-crisis, what alliances do you have now? Do you know your incident command? Do you have a network of trusted doctors and op docs who can be called maybe that rapid response team that was talked about earlier? Developing consensus recommendations and testing messages, that's pre. Initially, always, you need to be able to acknowledge the event with empathy. That's not false. It's not just being PR. It's so that people know that real humans care about what has occurred and are going to be committed to doing the best to protect human health and the environment. Then you have to explain and let people know in simplest terms what we know and what we don't know about the risk. That's your time to establish some credibility and then provide emergency courses of action, which may change over time. I think even in the East Palestine example, there's certain people were told to evacuate, and then the area grew, and that confused a lot of people. Again, letting people know that things might change, but we're committed to giving you information throughout the response. That initial phase could go on for a long time as we learn more information. Maintenance is maybe that's a misnomer, but that's as you start to get your footing more on what's happening and what's occurring and then what you're going to be doing about it. Again, I don't have time to go through all of these, but you could think about this as a template for coming up with initial messaging and messaging throughout to say, wow, have we gotten support for our response? Have we listened to stakeholders and gotten their feedback? Again, no matter where you are, you can look at this and think about what are we doing with respect to the specific disaster we're talking about and how to respond. I have to acknowledge, of course, that this is not easy to do, especially in a disaster response situation. I've got just a few of the reasons why. I already alluded to the fact that there's often lots of uncertainty in data. Then there can be uncertainty in health effects because of a number of things. We don't really know who's exposed, what all the chemicals are. We don't have great ways of assessing risk for mixtures. There's lots of uncertainty. In the case of East Palestine, we didn't even know all the chemicals initially. They thought it was one thing. Then there were a number of other things. Again, multiple and conflicting interpretations of the data. We've got this disagreement that happens. It's important to figure out who is being perceived as an expert. If you're not part of that and you think you really hold the scientific or medical expertise, that's a problem that we need to address. Terminology can often make another communication dilemma. I think in the case of East Palestine, this whole notion of controlled release really created a lot of concern, confusion, and controversy. Even when we're taking an action, the language that we use for that action, if not adequately explained, the reasons for it and how it will either help protect can lead to more problems. Again, lack of data addresses an individual's concern. Am I safe? Individual. In this case, we had lots of different stakeholders we could think about. Perceived delays and release of information. You've got some data. You don't have enough data. You need to let people know what you're doing for sampling and to find out and then getting the information back. These are just a few of the things. We could probably do a whole session on what just happened for East Palestine in each of these blocks. Let me give you some keys to effective risk and crisis communication. First and foremost, really, is G equals T plus C. The goal of communication must be to build trust and credibility. That's really the basis. If you don't have trust and credibility, nothing will matter really after that. I'll go to other sources of information. Be proactive, not reactive. That means having that emergency preparedness and response plan, knowing who's going to communicate, knowing who do you call on in your community if there's an incident, who's trusted by the community, who's trusted by the workers in terms of being able to respond, establishing a spokesperson and getting approval for the chain of commands. Often, it's that not having the approval for the chain of command that can create many, many problems and dilemmas. We see this in lots of big incidents. Clear goals. What am I trying to communicate at the beginning, at the middle, during the end? Again, knowing why you're communicating is as important as what you're communicating. We'll talk more about identifying and understanding your stakeholders. Only then can we come up with the messaging that we need to have. Ensure consistency or explain discrepancies is really important. For example, you just heard from Theresa talk about that nitric acid liquid. Who would be at risk for that when people might think, well, it's not a toxic vapor and should I be worried? Messaging, explaining early on the differences that people may not understand at the get-go becomes important as well. Using lots of different channels and then monitoring effectiveness. Again, here are some of those goals. It will depend on where you are in terms of that. Now we get to what do people want to know? It doesn't matter what the situation. These tend to be the types of concerns that people have. Let's look at some of those. This will happen in every situation. What does it mean to me? What does it mean to my family? What are the risks now? What are the risks long-term? What are the health effects? In the case of East Palestine, again, what's a controlled release? Why did you do it? That was a big concern. Wasn't that riskier? Can you really detect all the contaminants? Then, of course, is any level safe? Then what else don't we know? Again, a short list. If we don't address the health and safety concerns first, we're not going to be able to get people to think about the other information we want to provide. Then environmental concerns, again, fish kills and contamination of water, air quality, biota, livestock. We'll often see in a disaster that after you've addressed the initial health and safety concern, people then start to think about these other environmental concerns. We have to be prepared at a certain point in our messaging to give them information on that. Lifestyle concerns. I can't use my home. Can I shower? Can I wash my clothes? Loss of recreational areas, gardens, livestock. In the case of East Palestine, again, there are people who are still in hotels right now thinking they can't go back into their homes. We clearly saw that type of stuff happening with 9-11 as an example or in the BP situation. A lot of things about the lifestyle and people want to know what that means to them and their families. Then it goes into the economic concerns. Who's paying for my hotel? Who's going to pay for the medical liability and the monitoring, not just today in terms of the screening, but if I end up having health effects two years from now, five years from now? All those things will also come up. I want to point out this notion of aesthetic concerns. When there is a visual impact, and in most of these incidents, there is a very glaring visual impact. We see the smoke, the colored smoke. We hear noises. We smell odors. That's an indicator to people that there is a health concern. We need to start to learn how to tell people what that means and not just say it's a low odor threshold or that doesn't mean you have a health effect. Again, we need to explain and help people understand what we know and recognize that if there's a visual impact, if there's noise and odors, people are going to ascribe it to health effects. Then after we do that health and safety and environmental and lifestyle, then people worry about the data and information. How much data do you have? Is it enough? What don't you know? Is this what caused my symptoms and illness? There are some equity concerns. Why aren't my evacuation costs covered? That was another thing that came up at the recent NASEM two-day committee hearing that was held this week, I think, or last week. I was only a mile away. Why didn't they cover me? What was the mandatory evacuation? Why was it so small? Why did it take so much time for it to get expanded? All those things will come up. Again, trust and credibility tends to trump these things. Who makes the decisions and how? Always, people want to know how they can get more information. I want to talk a bit about risk perception. It really is fundamental to understanding risk communication because it's related to how people take in and process health information and environmental information and technical information, and also about how people will do their own health behavior decision-making. If people feel at risk and if they don't trust you, they're going to start searching for more information to confirm their initial beliefs. We have to be careful about that. Risk perceptions are not misperception. It's a differing perception. It's influenced by a wide variety of different factors. Some are cognitive, some are motivational, and some are affective. There's been research that shows that there are about 18 different characteristics that have been identified that can lead to a difference between how the technical expert, maybe all of you as op med docs or health officials, versus the public or workers. We have to understand these differences and think about how our communication may impact those. I mentioned there are 18 characteristics. I have 12 here. I have time to maybe just hit on a couple as an example. This is an important slide because this is something I'd like to have people think about any time there's an incident. I want you to think about which of these factors are likely to be stoked, if you will, and then their impact, both on the perception of risk and how to communicate. The first is whether or not a risk is voluntary or involuntary. Clearly, when we have an incident, East Palestine, most spills, it's an involuntary risk. When something's an involuntary risk or perceived as being involuntary, it automatically increases perception of risk by some researchers two orders of magnitude. Similarly, if it's controlled by others, and the others now could be all of you who are doing the response, again, can increase perception of risk by up to two orders of magnitude. Now, what do you do about that? Well, a couple of things you want to do is not make comparisons between things that are voluntary and under someone's control, so something that's involuntary and controlled by others. In the recent incident, again, I saw, and even in terms of some of the media coverage that I was looking at for East Palestine, when there are comparisons between, for example, well, what was released is similar to what you might find in your garage or under your household sink, right? When those types of comparisons are made, it tends to reduce credibility and increase perception of risk. If something is a carcinogen, it's dread. Dioxin is a dread substance, and so when people hear dioxin, even biochloride, it immediately increases the dread factor. It affects human origin. All these things on the right-hand side were really at play in the East Palestine train derailment. Lots of uncertainty, and again, the trust. I was struck, again, in that National Academy meeting that I just listened to about how the participants from the community felt like the sources they least trusted were the official sources. That's a problem for us. We already know that there's a problem in terms of belief in facts and science. When those of us who really have the expertise are no longer trusted, that's when it's a problem. If there's potentially catastrophic consequences, and again, visual cues can be an indicator of that. If you look at East Palestine, most of the things on the right-hand side were at play, and then the media tends to basically talk about all those things when they're writing their stories and reporting on it. I mentioned trust and credibility. It turns out that of all those factors impacting perception of risk, trust is the one that impacts it more than anything else. We've done a lot of research on trust and credibility, and we know how people are perceived and how you basically can get the characteristics of a trusted source. They're not what we would typically think about, especially when I think about an incident in command. The first is empathy and caring. If it's not right there at the get-go, you don't get the points. Are we able to communicate with empathy and caring at the beginning and throughout? Competence and expertise, yes, but only 15 to 20 percent. Honesty and openness, 15 to 20 percent, and then commitment and dedication, another 15 to 20 percent. We'd like to think that credibility is going to come by. We are the experts. We know, but in fact, that's only 15 to 20 percent of your source credibility. 70 to 80 percent, 75, 80 percent, 85 percent are from these other characteristics, and so we need to think about how are we showing that. More research on trust and credibility. This is some work that I've been involved in for a number of years. We've done a lot of research to think about who the public perceives as being credible, and I'll put workers in this as well. Typically, at the top is local citizens. They're perceived as neutral, respected, informed. Workers, union workers, again, right at that top. Again, in that Mason roundtable, there were many people who talked about who they went to, and they went to other people that they knew, people who lived in the area. Those were the people who were seen as being most knowledgeable about it and informed. Yes, health and safety, and luckily, all of you, nurses, physicians, firefighters. Emergency responders can be up there. Our job is to make sure that we're not doing things to reduce our trust and credibility. Then, professors, educators from local institutions, so that's important. In the middle tier, we have clergy and nonprofits and environmental groups and even the media, although the media has moved down. Cable is not trusted, but other media can be. If this was a log chart, I would show you that at the very bottom of all of these is state and local government and federal government. Again, as it was stated at that roundtable, people saw that the least trusted source of information was EPA, CDC, and the state health officials. That's awful, right? They were going to a whole bunch of other. They searched out on the internet. They did a number of other things, and so they weren't coming to the experts for the information. What's the answer? Building your own trust and credibility in advance and then during, obviously, any type of incident response. Uncertainty, again, not knowing things. Uncertainty is really, really key again and is another important risk perception factor. I think we all recognize by the nature of the work that we do that uncertainty exists. We also realized that I gave a training two days ago to a state department of environmental protection, and one of the participants said, yeah, but science by its very nature builds on itself. We don't know everything at once. Very true, but that's not how lay individuals or workers may perceive it. They tend to look at changing and incomplete information as a sign of uncertainty or that you just don't know what you're talking about, and that's when they go to these alternate sources. We have to be aware of that. What types of things are uncertain? Again, who is exposed to what? The magnitude, the duration, all the things that were mentioned in terms of the potential for things that we should be monitoring people for, which is great. The sooner we can tell people about that, we can tell them this is how we're going to reduce the uncertainties that we have, and this is the way that we're going to give you the information to follow up. Now, what happens is when there's lots of uncertainty, people will discount scientific models in favor of their own personal or intuitive models of risk. I saw the plume. I smelled it. I got a headache. How can you tell me it was okay? I was nauseous. These are things that I hear typically at a number of incidents when the experts are saying, you're worried. Well, we don't think there's a risk. We have to realize that there's this discrepancy here, and we need to figure out how to fill the gap to, again, be able to have effective communication. Use of a lot of hedging words will only increase uncertainty. Something as simple as providing the uncertainty at the end is, again, a way that increases it. Instead of ending on uncertainty, and of course, we don't know everything yet, as an example, you can say, and of course, we're going to continue to keep you informed as we gather more information. That's also a way of flipping a negative to a positive statement. So these are some of the things, again, that are important for effective messages to include. One of the things I like to do is I like to give people a model, make it simple for everyone, kind of give you a little cookbook, if you will, to how to take all the enormity of information you have and then put it back into that stages of communication. Always active listening. You need to know what your key stakeholders want to know and when. It will change over time. So you can't just disseminate information. You have to have feedback channels. Then short, clear, concise messages of what your key findings are. That could be what you know at this point. Then a couple of facts that support those key points. Repeat the key message because, again, we know that people need repetition for the message to sink in. Don't be afraid of saying it the same way twice or even three times. That's what people need. And actually, when people are very, very upset, they actually need to hear something up to six times for it to stick. And then always end on the next steps and the follow-up. How you can get people more information, how they can get more information, and what you're doing to resolve uncertainties. So again, here are some of the takeaways, the keys to effective messaging. Prepare messages in advance. You've got to work as a team. Doing everything you can to avoid jargon. That could even be about your own organization. Try to use terms that people understand. That doesn't mean, quote, unquote, dumbing it down. Talking in storytelling mode or narrative mode so people understand things. Highlight the need to know information and repeat it. If you're doing written communication, sometimes we do that with bold or offsetting boxes. But really thinking about how you bracket it. Avoid talking in negatives. Don't end your message on uncertainty. Again, end always on what else you're doing and ways to resolve uncertainty and how else people can get information. Continue to provide updates in a timely manner, even if you don't have anything new to report. We said we're going to come back out in two hours. Here's what we can tell you now. And then again, you may be coming out there in another two hours. So people see that you're actively trying to be responsive and adjust the situation at hand. And always throughout, communicating with empathy and demonstrating dedication. I've talked a lot about uncertainty already, so I won't say more about that. So when you're talking about monitoring, whether it's medical monitoring or doing the environmental monitoring, that's really important. Monitoring is a way that we resolve lots of uncertainties. And so I think we need to tell people about the monitoring and how we might plan on expanding our monitoring as we learn more. This bit about negatives. Many people tend to speak in negatives. There is no indication to suggest that there may be a negative effect. We do not think you are at significant risk. Those are all negative messages. And so this is the toughest part of risk communication, to try to frame these things in more positive terms. And it can be done. I love this next one. This is from BP. It wasn't our accident. We're not responsible. But we are absolutely responsible for the oil, for cleaning it up. And here's what we intend to do. Well, the last part of that was kind of lost because it wasn't our accident. We're not responsible, right? So when you have a compound message with lots of negatives, you lose the listener as well. And the next one as well, what's failed is the ultimate safety of the drilling rig. There are many barriers of protection that you have to go to before you get to this. It isn't designed to not fail. Wow, there's one for occupational health and safety folks to stay away from. We see this last one in a lot of reports. There's limited or suggested evidence of no association between the trail derailment and your symptoms or disease. That's a negative message. So we have to think about how it takes a little bit of time, but how we can say these and frame these in more positive terms. OK, so to summarize, communication is a critical part of disaster response and preparedness. Plan for it and think about it throughout, not just at the end. Understand and identify your stakeholders. And then you need to create messages that address their concerns as well as your own needs. Understand and address risk perception while you're developing messages and as you're listening to responses or reading what's in the media. Be a credible source of information. In that East Palestine train derailment, there was a retired fire chief who actually was giving contrary messages. That created a problem. So again, you need to know who other people are going to as a credible source of information. And then you've got to be that credible source. And last but not least, use appropriate channels and maintain communication throughout. And with that, I know we're going to be opening it up for some questions, so I'll stop my share. Hello, everyone, and thank you to all our speakers, Dr. Santos, Ms. Einhart, and Dr. Tringle. Unfortunately, Dr. Tringle is not able to join us for the Q&A, but Dr. Berenji will be able to answer questions regarding his presentation. So thank you, Dr. Berenji. And I think in the last presentation, there was a comment, information does not cure wrong perceptions. I really like that. It reminds me a lot of what was going on during the pandemic. And the presentation really reminds me of the parallels, of course, of having crucial conversations and in one-to-one patient care as well. So we're going to open up for question and answers. We have a question here that says, it seems like stakeholder propensity to trust would be important in adopting communication strategies. How do you use your knowledge as stakeholders to adjust your approach to a given group? So I can answer that, and then I'm sure, Teresa, you may have another response as well, because I love those different stakeholders you put out there. And I deal a lot with people in terms of also cultural issues and language issues, right? And so I think, again, if you can address that stakeholder's top concern, and sometimes I do it by looking at other disasters that have happened or similar type of situations, and I always try to find out where they're getting their information from. And then I'll also try to find out where they're getting their information from. And then I can adjust my message in terms of thinking about the channels they use. So if the channels that they use are very, I can think of one situation in Illinois where we wanted to get the message out about not eating the fish, and we didn't recognize and understand that that Latino population was a sustenance population, right? Or indigenous population that's a sustenance. So to think of them as a non-indigenous person or a non-Latino would not work. So we have to use other intermediaries who can get those messages across. That's just one example. Ms. Enerdy, do you want to add anything to that? No. Just along the same lines that we work on preparedness and planning and response tactics every day. We have a large state. We have a lot of people. We have a lot of snowbirds. We have to have a mechanism to communicate very broadly, but more importantly, a trust relationship on knowing that when the call happens, it will be answered. And we'll do our best to provide the necessary resources. So here in this state, we have 15 county health departments and 23 federally recognized tribes. And we're a border state, so we have a very diverse group of individuals that we provide resources to. Great, thank you. So I was wondering, how can ACON members, occupation environmental medicine specialists, leverage our expertise to be the ones to be called on during disasters to address the risk communication, as well as in the media, for example? I haven't thought about that. If you want me to share it, I can. And then I know, Dr. Moran, you may have something as well. But I will say, as an example, there's a pediatric environmental health, the PESHU units that exist through many states. And those are the places that awesome community members go to, because then they're worried about their kids' concerns or toxicity of different chemicals. I think we need something like that for ACMED, that there is that group of experts that are seen as neutral, not always just advocating for an agency or an industry, but that's broad enough that has the expertise. And that may mean doing trainings for people and may mean making yourself available as resources. So that's just one idea. But I do think that that would be critical to have that type of cadre, because there'll be another incident that's going to come up sooner rather than later. And instead of people going to the internet or finding their own person, working with trusted, again, ACMEDs is, I think, an important way to go. Yeah, I had some additional comments on that. I know there's been a lot of interest within ACOM to be able to develop what's called an environmental rapid response team. I know that these conversations are ongoing, but clearly there is a need for having subject matter experts to be able to provide information in real time. I know a lot of times the information may not be completely vetted, but I do feel that we have the knowledge base to at least provide some initial, at least evaluations of the circumstances, and then lead people towards reputable sources of information. I was a little dismayed to see what was happening with the National Academy session last week. I did attend that, and to see the community members actually not have faith in the CDC, I mean, that broke my heart. And we really want to make sure that people know where to get trusted information. And I think we can be that conduit. Right, I'll just add that. I think one of the reasons that happens too is because of all the controversy we had over COVID, right, and COVID vaccine. And so that was a credibility hit, even though it's a different administration, different kind of time. And so I do think that that rapid response group would be great. I would implore you to add communications folks to that as well, people who know how to help you communicate what you know effectively to those key stakeholders. Absolutely, thank you, Susan, appreciate that. Yeah, just one little add on real quickly is the getting back to the trust relationship. And I agree with Dr. Santos about the lack of trust from COVID. So we're kind of back to ground zero, but there is opportunity for intersection with this group at our national summits for not only the public health, but also the healthcare coalitions. I think it's really important. I listened last week and I was amazed at the amount of collaboration and coordination it takes to find the right medical specialists based on the event, very similar to the Boston bombing at the marathon. So we just have to keep at it and build the trust relationship with the federal partners that come to the rescue, we hope. And then our collaborations with groups like this. So there is a request from one of our participants, would Dr. Santos mind providing a suggested reading list concerning risk communication? There's a lot out there. There are several books on risk communication. I would definitely tell people to look for the work that's been done by Paul Slovak, as an example, and Granger Morgan in terms of risk communication. But there is that you can go on to the Society of Risk Analysis and there's a whole bibliography there of reading that you can do. So there's a plethora of communication and the research continues to be done. And that CDC Synergy course that they developed, and this was again, right after 9-11, that's pretty good as well. That's got a lot of good information there and a lot of resources. So there is lots of reading out there. I am constantly reading the latest research on it because every day there's a different risk, whether it's a disaster response or whether it's the next super bug or whether it's, you name it. And I've dealt with everything from mad cow disease to H1N1 to SARS to COVID to chemical spills and dioxin. We have to do a better job of realizing that the scientific data alone is not gonna solve our societal issues with how people can take in and process information. Great, thank you. There's a lot to be discussed here. We have to go to our next session but there is another question in the question and answer box so maybe if you're okay, one of you answering in the question and answer box and we can go on to our next session. Again, I wanna thank all our speakers for participating in our panel here today and we'll just move to our next session. Thank you. Thank you. Our final presentations of the day will address climate change, New York City haze and wildfire smoke impacting workers' health in the urban metropolis. Our speaker is Dr. Ismail Nabil. Dr. Nabil is an associate professor in the Department of Environmental Medicine and Public Health at the Icahn School of Medicine at Mount Sinai. Dr. Nabil has expertise in internal medicine, occupational and environmental medicine and clinical informatics. He has always been interested in climate change and its impacts on workers' health in multiple different working environments. Over the course of years, he has published a series of articles providing in-depth guidance on the clinical competencies for occupational and environmental medicine practitioners to protect workers' health in the impending climate change crisis. He was instrumental in the development of climate change specific podcast called Climate Conversations, exploring the impact of climate change on workers' health. For the past five years, he has been working on the development of Pocket Arc, a collaborative effort to enhance the health and safety of the construction workers working in the flood zones. In 2023, he also received the P30 grant on climate change and health, which looks at the flooding and its impact on respiratory illness. Hi, everyone. Thank you so much for joining me today for this very important topic about climate change. This is an event that occurred very recently, affected all of us here in New York. And I witnessed this climate change event and experienced it. So I'm happy to bring it all together today We'll be talking a little bit about wildfires and changing climate. I'm talking about New York City haze, wildfire smoke impacting worker health in an urban metropolis. I have nothing to disclose. I work for Department of Environmental Medicine and Public Health at Icahn School of Medicine. And there's no disclosure regarding this presentation. Wildfires and air quality, I think there's a tremendous link between the two. There's no question that as we have seen more and more wildfires impacting the air quality as the world is changing and climate change impact has been felt across the globe. Wildfires have been much more on the horizon and that has impacted air quality and health in general. I want to start with Nova Scotia wildfires which was the Canadian wildfires that were start to burn during the summer months in Canada. This was a little bit unusual because the Eastern seaboard, Canadian Eastern seaboard does not have that many events of wildfires compared to the Western front. But the Nova Scotia climate was heavily influenced by the North Atlantic Ocean which brought high humidity, moderate temperatures and fires were unusual usually as I stated compared to the West part of the Canada. The region itself is covered by a Acadian forest which has plenty of broad leaf like sugar maple mix with evergreens and conifers. So these leaves are fairly flammable and that can produce a lot of not only moisture but smoke when they start burning. And that's exactly what happened late May when the heat wave pushed the temperatures to pretty high 91 Fahrenheit. And that basically potentially started the wildfires in that area where the fires were burning unchecked. And partly human activity was also noted to be the case in any wildfire scenarios. Living in New York City, you admire the skyline for sure. The big towering skyscrapers that is part of New York. Fabric, it's an urban metropolis right in the distance. You can see the One World Center that was built after the same site where the World Trade Center stood. But the rest of the city is basically remodeled for an amazing skyline. And that is also true during the night. So you can actually see a significant amount of New York particularly the Isle of Manhattan from any distance from the bridges, from the marshes out in the beaches. You can look back and you can really see the New York skyline. And New York is a vibrant place where it's sort of a mini Hollywood. Most of the movies are filmed in New York and there's different shows that happens throughout the year in New York. So I wanna present something, a case of Hector who's a camera operator who's been working in New York for a long period of time. He usually started out as shooting commercials in New York City. The mayor office also support this work, increased jobs. There's a lot of community of cameramen, actors, extras that actually come into New York City and film from commercials to mini series. Lots of shows that you see on the TV are filmed here in New York City. So Hector landed this major gig for major motion picture as a huge career opportunity for him to be part of this project. Filming was scheduled at the time in New York City and this was the second week of shooting. So everybody's was on the set and suddenly what we see is this orange sky that you can see on the left. The picture I'm showing you is about the sky which is supposed to be blue with sun, with a clear day is completely covered with smoke and dust. And then the sun is peeking through this smoke and you cannot even, you can directly see the sun in the sky. The air quality became unbearable. The sky looked hazy as if there was a campfire brewing and smelled as if there's a lot of wood burning. The members of the crew, as he stated, experienced high and throat irritation. They had breathing difficulties. They couldn't act their part outside. So what they did during the filming, they passed out the skin, 95 masks for everybody that was left over from COVID. But mask helped a little bit, not much. Air was fairly thick as it was harder and harder to breathe. Actor himself is asthmatic. So he started to have trouble breathing. He wore the mask within the haze, but the air quality was fairly significant. So he started to wheeze and he couldn't continue working as a cameraman on the set, ended up leaving the set. And he was very worried at the time that how he's gonna complete the project. This is the second week and they have to cancel the recording altogether. Skyline was completely covered for a very large area in New York City. It was not only impacting the main metro area, but this is a place I leave from work and the parking lot, I took this picture, showed the same scenario here in a suburban site of New York where a certain smoke completely covered the skyline and you can barely make out the sun, which is glowing in the back. So this was Westchester County, which is a huge area north of New York, which is also covered by smoke. When I came into the city, usually most people take subways or trains to commute. This was a similar scenario. The one thing that I want to highlight here, which is part of the urban metropolis, is Most of the work gets done by walking to the destination or taking a subway. Most of the city dwellers take pride in walking down the block. If you've ever been to New York City, you can imagine that the work is usually done outdoors by walking or people taking bikes and other modes of transportation to do the service. Most of the delivery men are outside and most of the deliveries are done through this mobile bike service. It's very common to see that people are out and about in the city during early hours and late during lunchtime. It was a different day altogether. New York has been scarred with the COVID pandemic. Wildfires was a new challenge that we faced altogether. This is the skyline that I talked about earlier. It's hard to make out whether we are seeing the sunset or a sunrise because it was completely dark. On the right is a time-lapse photography, which actually shows you the different phases of how the smoke engulfed the city. Basically you can't even make out the buildings on the right side as the smoke got thicker and thicker during the day. Most people started to see there's a heat index, air quality index was published. People started talking about where are we as far as air quality is concerned. At the time when I was in the city, we were in the purple range, so about 201 to 300. We were dealing with very unhealthy air quality index. At one point we hit maroons, which is 301 to 500 air quality index, which requires not only the sensitive group, but everybody who is not sensitive to smoke need to take shelter or cover. Any outdoor activities are prohibited because that can have a detrimental effect on your health. We actually started to hit maroon during the day when the wildfires or smoke were significant. This is kind of giving you a scenario near the hospital. Outside you actually cannot make out the buildings, so if you go see, you can start to see the buildings being completely covered in smoke and soot. You can't make out whether there are buildings beyond the sight of vision. The picture on the lower side also is Central Park, which is, you cannot, the trees were covered with smoke and soot and it's very hard to breathe. The picture on the left-hand side demonstrates some of the workers who come in, work in the city, they're Uber drivers, they're also delivery persons who deliver food during the lunch hour. So you can imagine how significantly difficult it is to ride a bike or to walk from one block to another during this time when we're experiencing. I took out my trusty N95 at the time and wore it because I was starting to feel the effect of the smoke. I don't have asthma or I don't have hyper-responsive lungs, but it was hard to breathe for sure. What brings me back is this health impacts of climate change. When there's significant exposure, there are two things that happens in human beings. One is an adaptive capacity and then the sensitivity from the exposure and that defines vulnerability against a condition. So if I don't have bad lungs, I don't suffer from COPD or asthma, I do have some degree of adaptive capacity to tolerate some of the smoke that I'm inhaling. But if I'm part of the sensitive group, my vulnerability against exposure goes up significantly. That's a challenge per se in terms of evaluating workers or other individuals who have been exposed to climate change because every single time you are trying to address or trying to help someone who had been affected by wildfires, you have to understand that they have other challenges like heart disease, lung conditions, or hypersensitivity that they have against the exposure, which make them more vulnerable to smoke and exposures. The smoke can land you in an emergency room or you can tolerate it better. In my case, I was able to get back home safely and my shortness of breath was not as significant as somebody who has a lung condition. That's a very interesting point that I want to make when you are looking at workers' health because everybody has different vulnerability index based on sensitivity and adaptive capacity and the amount of exposure that they have at the time while working. Looking at Canadian wildfires, one of the challenges we had was this swift change of the wind direction and where the fires are burning. Canadian wildfire index, it's called fire weather index, is made up of an ISI, which is the initial spread index, and a buildup index. In simple words, what that means is the fire weather index provides valuable information about potential fire behavior based on weather condition and fuel status. That's very important because if you are predicting where the wildfire is going to be or where the direction of the wind is going to be, you really want to know what the fire behavior is going to be. One of the things that it does not take into account is the ignition sources or firefighting efforts, but these are just basic metrics that you can use to predict that certain municipality or zip code or locations can be impacted because the fire weather index supports that. In the picture on the right, the map on the right, you can see the western part of the country in Canada is hugely impacted by wildfires compared to the eastern side of things. There was a change that occurred and New York and eastern side got a significant amount of smoke from the Canadian wildfires that made it very, very difficult to function. What are the impacts on human health? Why are we worried about wildfires and smoke on human health? First, the air quality index that I shared earlier, we were 366 at the time. It was 24 times more than what the World Health Organization recommended as the exposure guidelines. We were at one point one of the worst cities in the world with the worst air quality in the world, which is fascinating as we take pride in being the cleanest city in the world. One of the significant things that we saw right away, and I alluded to it in the previous slides, is this vulnerable population. The ED or ERs were inundated with asthma-related cases. It was the highest increase in asthma episodes that we saw at the time. There's a lot of things to worry about when you're exposed to wildfires, cardiac arrest or premature birth, asthma exacerbation. We see it very early. One of the things that as occupational medicine, we know this, is there's a fine particulate matter about PM2.5 that is much smaller than the human hair, goes deep inside the lung and plays havoc with our health. The effects of this PM2.5 is much more long-lasting than a simple exposure of smoke and dust. Wildfires are responsible for many of the challenges that you see here. Whatever the fuel is, wildfire fuel like grass, sand, trees, vegetation, that can contain toxic chemical substances like carbon monoxide or carbon dioxide, sulfur dioxide, nitrous oxide, benzene, toluene, sirene, metals, and other dioxins. They can cause different kinds of effects on human body. They could be irritant, and then they can cause a significant shortness of breath and produce hypersensitivity-based reactions. Early effects of smoke and pollution is stinging eyes, which I had, burning of the eyes, runny nose, constantly dripping, post-nasal drip, irritated sinuses. You start to become pretty overwhelmed by smoke, start to have headaches, you have scotchy sores. Most people, if it's post-nasal drip, you can start to cough significantly. In patients who have hyper-responsive lung or have underlying asthma, it can lead to asthma attack with tachycardia or fast heartbeat and significant shortness of breath. Again, the effect is important because the substances can also cause additional challenges and issues in the body. As we saw, the vulnerable population was significantly impacted. New York City experienced one of the highest numbers of asthma visits in 2023, that day when the Canadian wildfire was raging on. The challenge here is not only the ED visits arose at that time, but the people who are impacted have a difficult time connecting with care because the EDs and other emergency rooms were significantly overwhelmed by this upsurge of patients. CDC launched advisory and basically saw an 80% increase in ED visits with wildfire exposures. This was published later on by CDC. One of the challenges, particularly in the urban metropolis like New York, it's not the same across all geographical areas. We see different counties have different disease patterns. For example, if you look at the Bronx population, particularly Queens and Brooklyn population, they're more vulnerable patients with high medical comorbidities that live in that area. It's a highly densely populated area. With wildfires, we started to see this demarcation very clearly. We saw this challenge with COVID and we saw this challenge with wildfires. More people and more vulnerable populations with comorbidities are living in this area, highly densely populated area. There we see a significant increase in ED visits. That goes with anybody who is working outside or doing deliveries. Most of the vulnerable communities, more people are doing day-to-day jobs of deliveries and others are more affected by wildfires. A graph on the bottom shows the biggest community that was impacted, which was Bronx, then followed by Brooklyn and Manhattan, where there's more affluent communities reside that are less impacted by wildfires compared to others. We also have morbidity and mortality weekly report, talked about the increased numbers of emergency room visits during wildfire smoke in New York in June, and there's increased concentration of 2.5, which is linked to asthma-associated ED visits. That has been seen across the New York City at the time of the exposure. We also have other issues to deal with, particularly with exposure to wildfires, cardiovascular, cerebrovascular events. Their analysis in the past showed that the smoke exposure associated with the cardiovascular and cerebrovascular events, and that triggers more ED visits. The most vulnerable population here is people above the age of 65, and I think I can argue the same way. The workers who are of older age are more likely to be susceptible to these smoke exposures and cardiovascular and cerebrovascular events. The wildfire caused increase in ED visits that we mentioned, 70% to 80% increase in zip codes where there are predominantly black and brown residents. You can see the Bronx communities have predominantly black and brown residents and higher poverty rates compared to overall city, and that's where we see increased number of ED visits from that sector. They have less coverage for their health. They're less likely to be seeing a provider to help with their underlying conditions. Sometimes people don't even know that they have asthma or other conditions, so they have been exposed with these triggers and end up in the emergency room with significant amount of shortness of breath. We also see an increase in mortality. There's a study done on wildfire smoke exposure in Washington State looking at a case crossover study from 2006 to 2017, and we saw increased odds of mortality in the first few days following the wildfire smoke exposure. That's the challenge we face in terms of the exposures to wildfire. It can certainly increase the mortality. We do need robust systems to understand the effects of climate change, particularly wildfire smoke and others on human health and affecting mortality in certain communities. This is a very interesting slide. This is not the June timeframe, but actually in September where wildfires and smoke density has been demonstrated by a map that's been moving from September 21st to October 2nd. One of the interesting things that you will see is in hurricane-based events, we have two or three days worth of change that we see a huge rainfall, and then the hurricane moves from one area into another. The smoke situation or density is different in different timeframe, which is demonstrated very well with this map. Not all areas that are impacted by smoke are, as you can see, affected at the same time. It's very hard to predict where the smoke will be and how it will affect an urban metropolis versus a rural community. An interesting map to think about when you're managing your workforce across different time zones in the U.S. What are the workers that are impacted and affected by wildfire smoke? Culture, forestry, fishing, construction, landscaping, highway maintenance, delivery operations, roof repair, oil and gas workers, wildland firefighters, first responders, teachers, the students, outdoor schools. Just to give you a perspective of New York, it has one of the biggest school systems. We were not anticipating this change in the environment in such a short period of time. Schools end up canceling the recess and break and sending kids back home because this event has impacted the kids a lot. The whole function of the city comes to a standstill as the wildfires were brewing. We also see some long-term impact on the health, particularly with chronic obstructive pulmonary diseases secondary to air pollution. There's definitely a short-term and long-term impact of wildfires on us. The biggest question is how we can protect workers. There are certain jobs that cannot be done indoors and a person has to be outdoor to help with the job functions. The map shows smoke plumes and air quality index in central states. We not only saw the change in northeast, but midwestern states were also impacted by the smoke from the Canadian wildfires. What can we do to protect the workers? First and foremost, if they're working outside, N95 might be a good protection for them. Taking breaks indoors at a time when the air quality index is very bad is very important. Well-ventilated areas, working outdoors is very important. That can minimize the effect of smoke on one's health. Avoiding strenuous activities, outdoor activity that requires a lot of physical work can be postponed for another day. Monitoring air quality index, I think that was one of the biggest things that I did when I was out and about or trying to get back home is trying to figure out what is the air quality index and how can I protect myself better. That's the same advice you can give to employees working outdoors. How can we minimize workdays and minimize the effect of these exposures to workers? There's also a public health message that communication needs to go out. The governor urged New Yorkers to take appropriate precautions from Canadian wildfires. there were advisories about the air quality from very unhealthy to hazardous. There's also targeted advisories to vulnerable communities which were impacted by wildfires. People with comorbidities, asthma, respiratory conditions are more at risk. And so there was a concerted effort to minimize exposure as best as we can. There was also a drive to send out N95 style masks publicly, statewide. And also there were alert systems that were updated in terms of air quality index across the commuter lines, transit systems, railroads. Wireless emergency messaging was also instituted. So there's a lot of ways to communicate these changes in real time to the affected community is very, very important. And finally, again, going back to the morbidity and mortality report from CDC, I think the lesson learned from the wildfires particularly in our case, and especially that goes very well for workers working outdoors is enhance the risk communication. We need to really hone in on the fact how can we communicate the risk to the vulnerable working population? That's important. We need to have a better focus on really looking at individuals who are more susceptible like people with underlying asthma, COPD. I had a chance to talk to a couple of my patients after the event and people who have asthma or COPD or other lung conditions were very much impacted by it compared to the ones who are not diagnosed with the condition. The other thing that I want to highlight is there's a racial inequality that exists among working population. And that's important to address. There are people who are more likely to be outside. They will be more likely to be delivering food or goods to different parts of the city. And these individuals, we need to prioritize them in terms of helping them figure out or get protected against these wildfires that can impact their health. Public health messages and strategies need to be prioritized to particular vulnerable population. And we need to think about the collaboration or strategies in order to help this working communities. And I think proactive messaging communication or letting them know, some workers might not understand how the smokes could be detrimental, particularly at that level to their lung. Even if you don't have a lung disease, a heavy or high air quality index can really impact your health differently. All these things need to be communicated well. And I think we can minimize the impact of wildfires on workers' health. And finally, going back in, we have recorded some of the podcast on this topic. And I think if you had a chance to listen to these podcasts, I think might help you organize and help your workforce better. And that concludes my presentation. Thank you for having me and I'm open to questions. Thank you so much, Dr. Naveel for your great presentation on highlighting the significant concerns from climate change and its impact on such a broad population, especially highlighting the disparities in populations that are vulnerable and traditionally underserved. So we're gonna get started with our question and answer session here. So we have our first question in our Q&A box. The question is, I have heard from some Midwest farmers that the growing season has been affected by the wildfires this year. Has this been studied and documented? Thanks, Alia, and for hosting this, I think the challenge is enormous. As you can see, there's not a one size fit all. And I experienced the urban side of things as was documented in the presentation. The question is about the farm workers in Midwest. And I think the scenarios are a little bit different. Personally, as I don't deal with farm workers, I have not had that experience, but I think the wildfires have a similar kind of impact in terms of the vulnerable working populations. If the smoke is there, you have certain effects due to the smoke and wildfires. But I think it goes beyond that, where there's livestock or animals are impacted during the wildfires. And the issue is just to minimize the damage at that time. The livestock could be severely impacted and there could be a significant number of mortalities in livestock. And again, the crop itself might be susceptible to the wildfires. Because as you can see that as the smoke or soot develops, the sun becomes completely covered. You can't even see the skyline anymore. So depending on how long the event is going on, and in our case, the community wildfires were going on since the summer months. And in September, October, we saw some relief in the smoke events. I think so that will impact the soil, the fertility, the crops that are beneath the sun. So it is a huge effect on the cultural side for sure. No question about it. But how do we address the farm worker health compared to urban workers working in the urban metropolis is a different kind of challenge that you can see evolving. So definitely there are colleagues who are much more focused on farm workers health. And I think that that might be a challenge for them too. Thank you. So, you were discussing vulnerable populations and the health disparities from wildfire smoke. How can we empower these populations? And have you been able to address this at an individual level or even a larger level such as working with local communities, unions, places of worship? Can you discuss a little bit about that? Right, so first and foremost is a one-to-one conversation with the patients. I think I treat some of the responders who were impacted by World Trade Center disaster. And I think the previous speaker talked a little bit about the event. It was a similar situation, the smoke engulfed them. They were completely covered after the event. And some of them, it was somewhat post-traumatic. They kind of felt that way again, that the smoke is there and burning wood has a certain smell that reminded them of being at 9-11. So that's a conversation beyond just the physical health, but also the mental health impacting these workers, these first responders. And so a conversation with them helped in order to understand what the impacts they were facing. Most of them have some degree of asthma and COPD issues or respiratory issues. And some of them are deeply impacted by the wildfires and some decided to remain indoors and were not impacted. As far as the population level intervention is concerned, I have some work in flooding scenarios where there's certain geographical areas that are flooded in New York City, which are densely populated. And I think the communication there is need to be more honest, need to be cognizant of the fact that the populations that I've shown in the slides in Bronx and Brooklyn area or Queens area, they have much more to lose if they are not working during the day. They are day laborers, they are hourly jobs. And if they don't show up to work or don't work outside or do delivery jobs, then they have so much to lose. So I think besides giving the advice of staying home, which is not possible for most individuals, I think we need to empower them with the tools or things that they can actually protect themselves. So very basic here is to provide them an N95 or give them information about what is a very significant event or in terms of wildfires that can impact you or remind them about their comorbidities. And that they have which might be more influenced by the wildfires. I also think that since COVID, there has been much more awareness in the communities in terms of the disparity that exists, at least in New York City and how we need to address that. It's a separate and very big question. And I thought you could discuss also from the, well, before we get to other questions that just came in. So in Montana, does smoke can lower the air temperature as much as 10 degrees? I haven't heard much in terms of impacts from the ranching and the farming communities here. Wildlife is far more impacted with large animals migrating out of wilderness into protected urban areas. I guess that's a comment from the last question there. Thank you. Yeah. So I was actually going to ask about regulations and standards. As you know, I'm not here in California. We're unfortunately very familiar with wildfires. I actually had one erupt right behind my house a few years ago. So I understand the impacts there. And we have the Cal OSHA standard protecting workers and impacted during wildfires. What is the landscape there in New York? And was there any changes made or any direction to change anything after that incident? So you're well said. In the West Coast side, you are definitely, are much more aware of the wildfires that from Oregon to California, Arizona wildfires last year have been significant. And so the public or population is much more in tune with the impact of wildfires on one's health in these states. And there's a concerted effort to bring legislation and to address these challenges. The experience in New York was more or less very unique. It hasn't happened. We don't usually hear about wildfires here in urban areas, let alone smoke circulating throughout the city and engulfing it in a way that it did. So this is a much more unique and nuanced conversation for the East Coast. The event lasted for a significant amount of time. The first event was much more profound than the second event. There was two times we have seen increase in pollution in New York City due to wildfires. The second event was a little bit more subdued and not as significant as was the first. As far as that helped move the legislative angle, I don't think so. At least I have not heard any nuance approach to wildfires. Again, the frequency of wildfires in New York is definitely much lower than what you guys experience there in the West Coast. And I think better legislation from your end might help move the needle here across the country throughout to the East Coast. But that's a challenge that we all face. Thank you. We have another question. Does the physical characteristics of a city such as the tall buildings, heat island effect affect the concentration of pollutants as compared to a more suburban or rural area? Oh, a fascinating question. The geospatial side of things that you are now inquiring about, there's a huge amount of data to support that the concrete buildings or pathways that New York has, it adds to the architecture of the city, but also increase heat islands, less movement of air across the buildings. The island gets heat up pretty quickly. We have a higher level of particulate matter that we see, particularly just because the geospatial nature of the city. So there's no question about that. There's much more research has been ongoing and been done in terms of air pollution. So greening the areas, decreasing the concrete footpaths, impervious surfaces that is very much New York, as you see has developed, has been responsible for much more thicker air than I would say rural communities. So definitely, and then again, you need to also understand the geography of the whole New York City. So if you have a Long Island, which is constantly being, there's ocean wind that sort of support that movement of the air, but Manhattan and Bronx area and up the boroughs, there's less degree of air movement that we see. So absolutely, but that's the biggest challenge in an urban environment where we see a lot more pollution and health effects associated with it. Is it really, really markedly sort of, we're well-informed about this geospatial nature and how it impacts the human health. I think jury's still out. There's a lot to learn from it. Kind of related to that, because I was also wondering about urban planning, but could you also touch on how might emerging technologies play a role in mitigating the impact of climate change on especially in urban air quality issues? Oh, wow. There's a lot of pieces to the puzzle. So I think collaborative work is needed for sure. The expertise I bring to the table is more focused on the human health and understanding how the pollution or PM 2.5 or wildfires are impacting human health. There's definitely a link that we have established over the years. There's a lot of literature supporting the connection between the two. So I'll start with my own domain first and then I'll move forward. I think one of the challenges that we have is particularly as we see patients or treat workers, we don't have a good documentation systems, right? To understand what the exposure looks like for these individuals. So we have electronic health record. We collect tons of information about the personal health, but never really document in our electronic health records to really connect the exposure aspects and the exacerbation of the condition that the patient is having. So I made the point whenever I'm seeing my patients, I usually write that the person was impacted by wildfires during this timeframe. And that's a first and very interesting step to understand or actually coalesce these data sets to understand the health effects related to climate change. So that's one of the work that I think all of us can do very efficiently because we are all occupational environmental medicine specialists and we see patients that were impacted by climate change. So I think that will help in better understanding of health effects. The second part to it, which is collaboration with other experts. So understand the geospatial aspect of climate change. We have flooding, we have wildfires, we have pollution, we have heat islands, we have heat indexes. So other scientists or communities are very interested in developing some degree of understanding about these effects, these exposures. And I think what they're missing from their end is a physician or a provider who can tie in the human health effects. They're very good at forecasting or predicting. We have amazing computer models that we can actually predict where the wildfire is gonna be, where the smoke's gonna be going, where the hurricane's gonna land and how long and how fierce it's gonna be. But we miss the opportunity to really understand the population that's impacted by these events. For example, what is the comorbidities in this population? How many vulnerable people are there in that population that's impacted by these events? So collaborating at that level will help minimize and improve our understanding of climate change and human health effects. To that point, are there collaborative efforts between New York City and other cities or counties facing similar challenges to share knowledge and best practices in dealing with wildfire smoke exposure and climate change? I think, and one of the key pieces in the presentation was MMWR report. It was the notes from the field. So CDC made a concerted effort to bring this overwhelming event, which we saw the huge number of people going to the emergency room and the emergency room getting overwhelmed. That was well publicized by MMWR. I think that was definitely a moment to cross-pollinate these ideas and how we can address climate change issues that we are all facing, including you in California, myself in New York. I think we can learn from each other. And my last slide sort of highlight that struggle that we have. We have issues with communicating the risks. We have issues with identifying the vulnerable population impacted by these events. And we need to really have a clear understanding of how can we protect these workers, these vulnerable working population without negating the fact that there are certain things that these individuals have to do for viability. So I think there's definitely a lesson learned here. And I consider CDCs and other public health agencies as partners to disseminate that information and learn from each other. Great, thank you. Thank you so much for answering our questions. I don't see any further questions at this point. So I wanna thank you once again, Dr. Nabeel for speaking to us on this critical topic. So we have come to a close to our day and I wanna thank all of you for joining us for day two of our virtual fall summit. And I wanna thank again, all our speakers for joining us and sharing their expertise. We hope to see you back here tomorrow for our final day which will cover clinical OEM topics. The start time is 11.40 a.m. Central, 12.40 p.m. Eastern. And we will be opening up the Zoom about five to 10 minutes before the day starts. Have a good day and stay safe. Thank you.

Libby Amphibole disease

risk communication

disaster situations

climate change

workers' health

urban areas

asbestos-related disease

vermiculite

pleural thickening

autoimmune diseases

research findings

trust

credibility

proactive communication

transparent communication