Air Aware: Improving Use of an Existing Air Quality and Health Tool.

Exposure to air pollutants is a significant health risk for individuals with asthma, cardiovascular disease, and chronic obstructive pulmonary disease. Measures such as limiting time outdoors or performing less strenuous tasks when air quality levels are better can mitigate these risks, but only if people are aware of both these recommendations and how to know when air quality is best, and worst. Formative audience assessment determined that applications developed for mobile devices are the optimal way to provide this information, but knowledge of the existing United States Environmental Protection Agency (EPA) and partners' AirNow tool was minimal. We developed, field-tested, adapted, and implemented pilot efforts at both the national and local levels to address this knowledge gap, and present findings suggesting a concentrated local effort can heighten use of AirNow, leading to more pro-healthy behavior.

COVID-19 response by the Hopi Tribe: impact of systems improvement during the first wave on the second wave of the pandemic.

The Hopi Tribe is a sovereign nation home to ~7500 Hopi persons living primarily in 12 remote villages. The Hopi Tribe, like many other American Indian nations, has been disproportionately affected by COVID-19. On 18 May 2020, a team from the US Centers for Disease Control and Prevention (CDC) was deployed on the request of the tribe in response to increases in COVID-19 cases. Collaborating with Hopi Health Care Center (the reservation's federally run Indian Health Service health facility) and CDC, the Hopi strengthened public health systems and response capacity from May to August including: (1) implementing routine COVID-19 surveillance reporting; (2) establishing the Hopi Incident Management Authority for rapid coordination and implementation of response activities across partners; (3) implementing a community surveillance programme to facilitate early case detection and educate communities on COVID-19 prevention; and (4) applying innovative communication strategies to encourage mask wearing, hand hygiene and physical distancing. These efforts, as well as community adherence to mitigation measures, helped to drive down cases in August. As cases increased in September-November, the improved capacity gained during the first wave of the pandemic enabled the Hopi leadership to have real-time awareness of the changing epidemiological landscape. This prompted rapid response coordination, swift scale up of health communications and redeployment of the community surveillance programme. The Hopi experience in strengthening their public health systems to better confront COVID-19 may be informative to other indigenous peoples as they also respond to COVID-19 within the context of disproportionate burden.

Air Quality Index and air quality awareness among adults in the United States.

BACKGROUND: Information about local air quality is reported across the United States using air quality alerts such as the Environmental Protection Agency's Air Quality Index. However, the role of such alerts in raising awareness of air quality is unknown. We conducted this study to evaluate associations between days with Air Quality Index ≥101, corresponding to a categorization of air quality as unhealthy for sensitive groups, unhealthy, very unhealthy, or hazardous, and air quality awareness among adults in the United States. METHODS: Data from 12,396 respondents to the 2016-2018 ConsumerStyles surveys were linked by geographic location and survey year to daily Air Quality Index data. We evaluated associations between the number of days in the past year with Air Quality Index ≥101 and responses to survey questions about awareness of air quality alerts, perception of air quality, and changes in behavior to reduce air pollution exposure using logistic regression. RESULTS: Awareness of air quality alerts (prevalence ratio [PR] = 1.23; 95% confidence interval [CI] = 1.15, 1.31), thinking/being informed air quality was bad (PR = 2.02; 95% CI = 1.81, 2.24), and changing behavior (PR = 2.27; 95% CI = 1.94, 2.67) were higher among respondents living in counties with ≥15 days with Air Quality Index ≥101 than those in counties with zero days in the past year with Air Quality Index ≥101. Each aspect of air quality awareness was higher among adults with than without asthma, but no differences were observed by heart disease status. Across quintiles of the number of days with Air Quality Index ≥101, air quality awareness increased among those with and without selected respiratory and cardiovascular diseases. CONCLUSIONS: Among U.S. adults, air quality awareness increases with increasing days with alerts of unhealthy air. These findings improve our understanding of the extent to which air quality alerts prompt people to take actions to protect their health amidst poor air quality.

Mold clean-up practices vary by sociodemographic and allergy factors.

We examined mold clean-up practices in a general population (not selected on history of natural disaster). We used a population-based survey (n= 3,624) to assess associations between sociodemographic/ housing/ respiratory health variables and mold clean-up, PPE use, and cleaning agent use. Bleach was the most commonly used cleaning agent with approximately 90% of residents reporting using bleach alone or with other agents. More respondents used gloves (76%) than any other PPE. The use of PPE varied; 42% of bleach users wore a breathing mask/respirator compared with only 19% of soap and water users. Hispanic populations frequently reported mold clean-up. Bleach use was less likely in the West and among Asians. Although "Green" products were rarely used, Asians were more likely to use them. Bleach was the most commonly used cleaning agent for mold, and PPE use was common when using bleach, supporting the need for current CDC safe use recommendations.

Communication channels for air quality alerts in the United States.

Short-term exposure to air pollution can result in acute health effects, particularly for individuals with respiratory and cardiovascular disease. Air quality alert programs that notify the public about high air pollution days are critical for susceptible populations. We assessed how U.S. adults receive air quality alerts and whether it varies by demographic or health characteristics. We analyzed data from the summer 2014 wave of ConsumerStyles, a nationally representative survey of U.S. adults (n = 4269). We calculated the weighted proportion of individuals who received air quality alerts from seven communication channels, combining all individuals and stratifying by demographics. To assess whether the reach of communication channels varied by respiratory and cardiovascular disease status, we computed weighted prevalence ratios adjusted for sex, age, race, and education. Forty-eight percent of U.S. adults had heard about air quality alerts. Within every demographic category, television was the most common communication channel (76% among individuals aware of air quality alerts). Other common communication modes were radio (30%), newspaper (24%), and internet (20%). Less common communication modes were friend or family member, mobile phone or device app, and electronic highway sign. The reach of communication channels varied by demographic factors, such as age, but not by respiratory or cardiovascular disease status. Television is the most common communication channel for receiving air quality alerts. Expanding use of other communication channels might increase awareness of air quality alerts. These results can help decision-makers target communication channels that reach susceptible populations and will achieve the greatest impact.

Patient-Provider Discussions About Strategies to Limit Air Pollution Exposures.

INTRODUCTION: Exposure to air pollution negatively affects respiratory and cardiovascular health. The objective of this study was to describe the extent to which health professionals report talking about how to limit exposure to air pollution during periods of poor air quality with their at-risk patients. METHODS: In 2015, a total of 1,751 health professionals completed an online survey and reported whether they talk with their patients about limiting their exposure to air pollution. In 2017, these data were analyzed to assess the frequency that health professionals in primary care, pediatrics, obstetrics/gynecology, and nursing reported talking about limiting air pollution exposure with patients who have respiratory or cardiovascular diseases, were aged ≤18 years, were aged ≥65 years, or were pregnant women. Frequencies of positive responses were assessed across categories of provider- and practice-level characteristics. RESULTS: Overall, 714 (41%) respondents reported ever talking with their patients about limiting their exposure to air pollution. Thirty-four percent and 16% of providers specifically reported talking with their patients with respiratory or cardiovascular disease diagnoses, respectively. Percentages of health professionals who reported talking with their patients about limiting air pollution exposure were highest among respondents in pediatrics (56%) and lowest among respondents in obstetrics/gynecology (0%). CONCLUSIONS: Despite the well-described health effects of exposure to air pollution, the majority of respondents did not report talking with their patients about limiting their exposure to air pollution. These findings reveal clear opportunities to improve awareness about strategies to limit air pollution exposure among sensitive groups of patients and their healthcare providers.

Air Quality Awareness Among U.S. Adults With Respiratory and Heart Disease.

INTRODUCTION: Poor air quality affects respiratory and cardiovascular health. Information about health risks associated with outdoor air quality is communicated to the public using air quality alerts. This study was conducted to assess associations of existing respiratory and heart disease with three aspects of air quality awareness: awareness of air quality alerts, discussing with a health professional strategies to reduce air pollution exposure, and avoiding busy roads to reduce air pollution exposure when walking, biking, or exercising outdoors. METHODS: During 2014-2016, a total of 12,599 U.S. adults participated in summer waves of the ConsumerStyles surveys and self-reported asthma, emphysema/chronic obstructive pulmonary disease, heart disease, and each aspect of air quality awareness. In 2017, associations between each health condition and air quality awareness were estimated using log binomial and multinomial regression. RESULTS: Overall, 49% of respondents were aware of air quality alerts, 3% discussed with a health professional strategies to reduce air pollution exposure, and 27% always/usually avoided busy roads to reduce air pollution exposure. Asthma was associated with increased prevalence of awareness of air quality alerts (prevalence ratio=1.11, 95% CI=1.04, 1.20), discussing with a health professional (prevalence ratio=4.88, 95% CI=3.74, 6.37), and always/usually avoiding busy roads to reduce air pollution exposure (prevalence ratio=1.13, 95% CI=1.01, 1.27). Heart disease was not associated with air quality awareness. CONCLUSIONS: Existing respiratory disease, but not heart disease, was associated with increased air quality awareness. These findings reveal important opportunities to raise awareness of air quality alerts and behavior changes aimed at reducing air pollution exposure among adults at risk of exacerbating respiratory and heart diseases.

Vital Signs: Asthma in Children - United States, 2001-2016.

BACKGROUND: Asthma is the most common chronic lung disease of childhood, affecting approximately 6 million children in the United States. Although asthma cannot be cured, most of the time, asthma symptoms can be controlled by avoiding or reducing exposure to asthma triggers (allergens and irritants) and by following recommendations for asthma education and appropriate medical care. METHODS: CDC analyzed asthma data from the 2001-2016 National Health Interview Survey for children aged 0-17 years to examine trends and demographic differences in health outcomes and health care use. RESULTS: Asthma was more prevalent among boys (9.2%) than among girls (7.4%), children aged ≥5 years (approximately 10%) than children aged <5 years (3.8%), non-Hispanic black (black) children (15.7%) and children of Puerto Rican descent (12.9%) than among non-Hispanic white (white) children (7.1%), and children living in low income families (10.5%) than among those living in families with income ≥250% of the Federal Poverty Level (FPL) (approximately 7%). Asthma prevalence among children increased from 8.7% in 2001 to 9.4% in 2010, and then decreased to 8.3% in 2016. Although not all changes were statistically significant, a similar pattern was observed among subdemographic groups studied, with the exception of Mexican/Mexican-American children, among whom asthma prevalence increased from 5.1% in 2001 to 6.5% in 2016. Among children with asthma, the percentage who had an asthma attack in the past 12 months declined significantly from 2001 to 2016. Whereas asthma prevalence was lower among children aged 0-4 years than among older children, the prevalence of asthma attacks (62.4%), emergency department or urgent care center (ED/UC) visits (31.1%), and hospitalization (10.4%) were higher among children with asthma aged 0-4 years than among those aged 12-17 years (44.8%, 9.6%, and 2.8%, respectively). During 2013, children with asthma aged 5-17 years missed 13.8 million days of school per year (2.6 days per child). Compared with 2003, in 2013, the prevalence of adverse health outcomes and health care use were significantly lower and the prevalence of having an action plan to manage asthma was higher. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Asthma remains an important public health and medical problem. The health of children with asthma can be improved by promoting asthma control strategies, including asthma trigger reduction, appropriate guidelines-based medical management, and asthma education for children, parents, and others involved in asthma care.

Characterization of Carbon Monoxide Exposure During Hurricane Sandy and Subsequent Nor'easter.

OBJECTIVE: Carbon monoxide (CO) is an odorless, colorless gas produced by fossil fuel combustion. On October 29, 2012, Hurricane Sandy moved ashore near Atlantic City, New Jersey, causing widespread morbidity and mortality, $30 to $50 billion in economic damage, and 8.5 million households to be without power. The combination of power outages and unusually low temperatures led people to use alternate power sources, placing many at risk for CO exposure. METHODS: We examined Hurricane Sandy-related CO exposures from multiple perspectives to help identify risk factors and develop strategies to prevent future exposures. This report combined data from 3 separate sources (health departments, poison centers via the National Poison Data System, and state and local public information officers). RESULTS: Results indicated that the number of CO exposures in the wake of Hurricane Sandy was significantly greater than in previous years. The persons affected were mostly females and those in younger age categories and, despite messaging, most CO exposures occurred from improper generator use. CONCLUSIONS: Our findings emphasize the continued importance of CO-related communication and ongoing surveillance of CO exposures to support public health response and prevention during and after disasters. Additionally, regional poison centers can be a critical resource for potential on-site management, public health promotion, and disaster-related CO exposure surveillance. (Disaster Med Public Health Preparedness. 2017;11:562-567).

Asthma education: different viewpoints elicited by qualitative and quantitative methods.

OBJECTIVE: This project began as a qualitative examination of how asthma education provided by health professionals could be improved. Unexpected qualitative findings regarding the use of Asthma Action Plans and the importance of insurance reimbursement for asthma education prompted further quantitative examination. METHODS: Qualitative individual interviews were conducted with primary care physicians in private practice who routinely provide initial diagnoses of asthma and focus groups were conducted with other clinicians in private primary care practices who routinely provide asthma education. Using the DocStyles quantitative tool two questions regarding Asthma Action Plans and insurance reimbursement were asked of a representative sample of physicians and other clinicians. RESULTS: The utility of Asthma Action Plans was questioned in the 2012 qualitative study. Qualitative findings also raised questions regarding whether reimbursement is the barrier to asthma education for patients performed by medical professionals it is thought to be. 2013 quantitative findings show that the majority of clinicians see Asthma Action Plans as useful. The question of whether reimbursement is a barrier to providing asthma education to patients was not resolved by the quantitative data. CONCLUSIONS: The majority of clinicians see Asthma Action Plans as a useful tool for patient education. Clinicians had less clear opinions on whether the lack of defined reimbursement codes acted as a barrier to asthma education. The study also provided useful audience data for design of new asthma educational tools developed by CDC.

Storm-Related Carbon Monoxide Poisoning: An Investigation of Target Audience Knowledge and Risk Behaviors.

Carbon monoxide (CO) poisonings in the United States consistently occur when residents improperly use portable gasoline-powered generators and other tools following severe storms and power outages. However, protective behaviors-such as installing CO alarms and placing generators more than 20 feet away from indoor structures-can prevent these poisonings. This study identified knowledge, attitudes, and beliefs that lead consumers to adopt risk and protective behaviors for storm-related CO poisoning and post-storm generator use. Four focus groups (32 participants in total) were conducted with generator owners in winter and summer storm-prone areas to explore home safety, portable generator use, CO poisoning knowledge, and generator safety messages. Discussions were transcribed, and findings analyzed using an ordered meta-matrix approach. Although most generator owners were aware of CO poisoning, many were unsure what constitutes a safe location for generator operation and incorrectly stated that enclosed areas outside the home-such as attached garages, sheds, and covered porches-were safe. Convenience and access to appliances often dictated generator placement. Participants were receptive to installing CO alarms in their homes but were unsure where to place them. These findings suggest a deficit in understanding how to operate portable generators safely and a need to correct misconceptions around safe placement. In terms of behavioral price, the simple installation and maintenance of inexpensive CO alarms may be the most important strategy for ultimately protecting homes from both storm-related and other CO exposures.

Risk and protective behaviours for residential carbon monoxide poisoning.

BACKGROUND: Unintentional, non-fire-related carbon monoxide (CO) poisoning is a leading cause of poisoning death and injury in the USA. Residential poisonings caused by faulty furnaces are the most common type of CO exposure. However, these poisonings are largely preventable with annual furnace inspections and CO alarm installation. OBJECTIVE: This study aimed to identify the knowledge, attitudes and beliefs that might lead consumers to adopt these protective behaviours. METHODS: In August 2009, four focus groups (n=29) were conducted with homeowners in Chicago, Illinois, USA, to identify the knowledge, attitudes and beliefs that lead consumers to adopt risk and protective behaviours. Discussions were transcribed and the findings were analysed using an ordered meta-matrix. RESULTS: Focus group participants were aware of CO poisoning and supported the idea of regular furnace inspections. However, few participants consistently scheduled professional inspections for fear of costly repairs and unscrupulous contractors. Participants often owned CO alarms, but many did not locate them properly, nor maintain them. Some participants confused CO and natural gas and were unsure how to react if a CO alarm sounds. Participants stated that incentives, such as discounts and inspector selection tips, would make them more likely to schedule furnace inspections. Participants also identified trustworthy sources for CO education, including realtors, fire departments, home insurance agents and local media outlets. CONCLUSIONS: Participants' residential CO risk behaviours are not random but driven by underlying knowledge, attitudes and beliefs. Correcting misperceptions, providing incentives and partnering with trustworthy sources might encourage greater consumer adoption of protective behaviours.

A review of disaster-related carbon monoxide poisoning: surveillance, epidemiology, and opportunities for prevention.

OBJECTIVES: We conducted a systematic literature review to better understand aspects of disaster-related carbon monoxide (CO) poisoning surveillance and determine potentially effective prevention strategies. METHODS: This review included information from 28 journal articles on disaster-related CO poisoning cases occurring between 1991 and 2009 in the United States. RESULTS: We identified 362 incidents and 1888 disaster-related CO poisoning cases, including 75 fatalities. Fatalities occurred primarily among persons who were aged 18 years or older (88%) and male (79%). Hispanics and Asians accounted for 20% and 14% of fatal cases and 21% and 7% of nonfatal cases, respectively. Generators were the primary exposure source for 83% of fatal and 54% of nonfatal cases; 67% of these fatal cases were caused by indoor generator placement. Charcoal grills were a major source of exposure during winter storms. Most fatalities (94%) occurred at home. Nearly 89% of fatal and 53% of nonfatal cases occurred within 3 days of disaster onset. CONCLUSIONS: Public health prevention efforts could benefit from emphasizing predisaster risk communication and tailoring interventions for racial, ethnic, and linguistic minorities. These findings highlight the need for surveillance and CO-related information as components of disaster preparedness, response, and prevention.

Attitudes about carbon monoxide safety in the United States: results from the 2005 and 2006 HealthStyles Survey.

OBJECTIVES: We sought to identify attitudes and behaviors related to carbon monoxide (CO) safety that can be targeted with public health prevention strategies in the U.S. METHODS: The Centers for Disease Control and Prevention added questions about (1) proper placement of gas-powered generators, (2) maintenance of fuel-burning appliances, and (3) use of CO detectors to the 2005 and 2006 HealthStyles national health marketing surveys. RESULTS: In 2005, 63.3% of HealthStyles respondents agreed with or were uncertain about the incorrect statement, "It is safe to run a generator in a garage as long as the door is open," while 43.1% agreed with or were uncertain about the incorrect statement, "It is safe to run a generator in the basement." Most of the 2006 respondents (63.5%) agreed that it is important to have their furnace inspected annually. However, fewer than half of the 2006 respondents (42.0%)-most of whom were homeowners-reported owning a CO detector. CONCLUSIONS: A large proportion of adults in the U.S. reported attitudes and behaviors that may place them at increased risk for unintentional, non-fire-related CO poisoning, suggesting that current safety messages may not be reaching much of the public. Prevention messages should continue to promote proper generator placement, maintenance of fuel-burning appliances, and use of CO detectors. Development of a comprehensive national strategy for CO surveillance and communication may help identify populations at increased risk and prevent future poisonings.

Public communication in unplanned biomass burning events.

Public communication related to emergency, unplanned, or "wildfire" biomass burning is best understood as a function of the audience for that communication. Two enduring communication models, the Health Belief Model and the Stages of Change or Transtheoretical Model, are instructive in analyzing and preparing differing communication response strategies that are indicated for communities with varying degrees of experience in responding to unplanned biomass burning smoke events.

Mold prevention strategies and possible health effects in the aftermath of hurricanes and major floods.

Extensive water damage after major hurricanes and floods increases the likelihood of mold contamination in buildings. This report provides information on how to limit exposure to mold and how to identify and prevent mold-related health effects. Where uncertainties in scientific knowledge exist, practical applications designed to be protective of a person's health are presented. Evidence is included about assessing exposure, clean-up and prevention, personal protective equipment, health effects, and public health strategies and recommendations. The recommendations assume that, in the aftermath of major hurricanes or floods, buildings wet for <48 hours will generally support visible and extensive mold growth and should be remediated, and excessive exposure to mold-contaminated materials can cause adverse health effects in susceptible persons regardless of the type of mold or the extent of contamination. For the majority of persons, undisturbed mold is not a substantial health hazard. Mold is a greater hazard for persons with conditions such as impaired host defenses or mold allergies. To prevent exposure that could result in adverse health effects from disturbed mold, persons should 1) avoid areas where mold contamination is obvious; 2) use environmental controls; 3) use personal protective equipment; and 4) keep hands, skin, and clothing clean and free from mold-contaminated dust. Clinical evaluation of suspected mold-related illness should follow conventional clinical guidelines. In addition, in the aftermath of extensive flooding, health-care providers should be watchful for unusual mold-related diseases. The development of a public health surveillance strategy among persons repopulating areas after extensive flooding is recommended to assess potential health effects and the effectiveness of prevention efforts. Such a surveillance program will help CDC and state and local public health officials refine the guidelines for exposure avoidance, personal protection, and clean-up and assist health departments to identify unrecognized hazards.

Acute idiopathic pulmonary hemorrhage among infants. Recommendations from the Working Group for Investigation and Surveillance.

This report presents CDC's recommended case definitions and surveillance practices for Acute Idiopathic Pulmonary Hemorrhage (AIPH). In 1994 and 1997, CDC reported clusters of acute pulmonary hemorrhage (APH) among infants in Cleveland, Ohio. Subsequent reviews of these investigations identified shortcomings in the conduct of the studies and concluded that the investigations did not prove an association between APH among infants and exposure to molds. In response to recommendations from these reviews, with assistance of external consultants, CDC staff developed a plan to conduct surveillance for and investigation of AIPH. In developing this response, CDC recommends a definition for a clinically confirmed case of AIPH among infants on the basis of evidence of blood in the airway, age