# Operation PPE -- Developing a Safety First Culture for Iowa Environmental Public Health

# 2007 - 2008 

# 

# Environmental Public Health Leadership Institute Fellow 

# Cory Frank; BA

*Environmental Health Emergency Response Coordinator;* Iowa Department
of Public Health

*321 E. 12^th^ Street, Des Moines, Iowa 50125*

\(515\) 281-8561

*[cfrank@idph.state.ia.us]{.underline}*

# Mentor:

### **CAPT Michael E Herring; R.E.H.S., MPH**

*Senior Environmental Health Officer;* Centers for Disease Control and
Prevention,

National Center for Environmental Health, Environmental Health Services
Branch

# (Acknowledgements):

### **Joy Harris; MPH**

*Executive Officer;* Iowa Department of Public Health

### **Carmily Stone; MPH, C.F.S.P.**

*Environmental Health Service Bureau Chief;* Iowa Department of Public
Health

### **Ken Sharp; BA, R.E.H.S**

*Environmental Health Division Director;* Iowa Department of Public
Health

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Prior public health emergencies such as 9/11, Katrina, and emerging
threats from Pandemic Influenza are solidifying the need for local,
state and federal environmental health as essential responders.
Everyday, environmental health specialists engage in potentially high
risk activities while delivering environmental services. They more often
than not, neglect the need for personal protection equipment (PPE). The
lack of a safety first culture transcends their ability to actively
respond to emergencies whether or not they are active in their response
communities. Over the past three years local environmental health (EH)
has been involved in public health preparedness planning efforts through
grant funding here in Iowa. Funds and training has been provided for
enhancement and reinforcement of preparedness activities. During 2007, a
resource typing survey was given to all local EH in Iowa and it was
disturbing to find that they severely lacked PPE despite 4 years of
funding and education about their roles in response and recovery
efforts.

Currently, the Iowa Dept. of Public Health has built, enhanced, and
established working partnerships within local public health by using
funding allowed by the Centers for Disease Control and Prevention. The
overall goal has been clear that local public health must be present
within the response culture within the State of Iowa. Local
environmental health was not active during the initial stages of this
process. The development of local environmental health response plans
has engaged these individuals to respond, but response has been limited
despite this initial success. The overall goal of this project is to
allow the local practitioner to feel safe while performing their daily
job activities, and promote their availability and a forward response
posture. To do this, the Environmental Health Services Bureau at the
Iowa Dept. of Public Health, is developing a safety first culture within
State environmental health programming and capacity building by
incorporating the safety first culture into local program deliverables.
Regional PPE awareness and general safety training is being developed
involving the Environmental Health Response Team (IA-EHRT), as a model
and a train the trainer curriculum to start this process moving in the
right direction.

# INTRODUCTION/BACKGROUND:

The need for this safety first attitude and agency culture has become
especially evident due to recent events involving environmental public
health factors, preparedness planning efforts, and local funding gaps
including:

● Recent emergencies that involved environmental health responders or
responders effected

> by environmental contaminants- such as the collapse and cleanup of the
> World Trade Center Towers in 2001, Hurricane Katrina, and local public
> health outbreaks in Iowa involving endemic fungal species and
> parasitic organisms like *H. capsulatum* and *Cryptosporidium*.

● Flooding events in rural Iowa have created the need for environmental
assessments by local environmental health specialists to respond to
local emergency management requests.

● Funding provided to local public health agencies has not incorporated
environmental health responders into agency safety programs if even
available.

● Local environmental health agencies have developed emergency response
plans.

The introduction and adoption of environmental health response plans for
local environmental public health was thought to be the first step in
the assurance that environmental health would be engaged in emergency
preparedness and response. The distribution of a resource typing survey
to all local environmental public health and subsequent adoption of the
majority of the local environmental health response plans showed that
there was a huge gap in having a plan to respond and being able to do
that safely. The chance that they potentially are at risk while doing
their daily job duties was apparent. The lack of basic protective items
to eliminate basic slip, trip, or falls, let alone environmental public
health hazards, was discovered. The traditional problem solving that the
Iowa Dept. of Public Health readily embraces of "create a plan and ask
questions later", potentially has exacerbated the problem of the
readiness of local environmental public health in counties or cities
where the engagement of environmental health is limited.

  --------------- --------- --------- ----------------------------- ----------
  Leather gloves  23 (29%)            Hand sanitizer                14 (18%)

  Latex gloves    8 (10%)             First aide kit                12 (16%)

  Nitrile gloves  43 (58%)            Ear protection                35 (47%)

  Tyvek suits     42 (56%)            DEET type insect repellant    39 (53%)

  Dust mask       30 (40%)            Shoe covers or boots (hip,    32 (42%)
                                      gum, waders, etc.)            

  Respirator mask 38 (50%)                                          
  (N95, P100,                                                       
  etc.)                                                             

  PAPR or forced  64 (94%)                                          
  air breathing                                                     
  device                                                            

  Goggles or      20 (25%)                                          
  safety                                                            
  glasses/pairs                                                     
  --------------- --------- --------- ----------------------------- ----------

Figure 1: Table Results from Iowa Resource Typing Survey **^4^**
indicating the percent of local environmental public health departments
that lack the indicated PPE item. The survey had 100 percent of all 99
counties in Iowa respond to the survey.

The attitudes and lack of knowledge of why using safe practices and a
general misunderstanding of PPE have been demonstrated. During the
initial launch of this project the following EMAIL conversation is an
example of the general lack of knowledge some of the local environmental
health practitioners have about PPE selection and practice. The
following excerpt came from an emergency manager and coordinator of
public health emergency planning for a county health department. The
reference is to the PPE checklist that will be given to PPE workshop
attendees this spring and summer:

*"On the Operation PPE Checklist, item #7 respiratory protection, lists
N95, N99, OR P100 as recommended. Just what is N95 -- these are
disposable for any worker or the public. How can this be fit tested?
Also, it refers to a Respiratory Protection Program. Do you have a
sample plan that we could review so as to develop? What is the minimum
expected? "*

####### 

####### ***Problem Statement:***

Why with the important role that environmental health plays in response
efforts in the post 9/11 and Hurricane Katrina era, do local
environmental public health practitioners not have adequate knowledge or
levels of personal protection equipment (PPE) or active occupational
safety programs?

To create a safety first attitude local environmental public health must
create and utilize safety programs and PPE on a daily basis to ensure
readiness and willingness to respond to public health emergencies. The
Iowa Dept. of Public Health must inject safety first messages when
delivering environmental health programming.

#######  

####### ***Behavior over Time Graph:***

####### ![](media/image2.wmf){width="6.625in" height="4.611111111111111in"} 

####### Figure 2: Behavior over time graph indicating the increase of risk to local EH increasing over time due to greater emergency response involvement and planning, even though the use of PPE has not substantially increased when quick fixes were applied. Financial resources have declined over time not allowing for PPE availability or stock of PPE to increase for local EH. The traditional problem solving methodologies have provided a seesaw behavior pattern for use of PPE by local EH. 

####### ***Causal Loop Diagrams and applicable archetypes:***

Limits to Success

Figure 3: Casual Loop diagram and archetype of *Limits to Success* where
the long term fix is developing long term safety first programming at
the State and local level to EH allowing them to eliminate occupational
risks daily enabling a response to local public health emergencies. The
reinforcement loop has been driving local EH to step up to the plate
with initial success but as the limiting factors, such as lack of PPE
and limited occupational safety training occurred, a developing
reluctance to respond has potentially limited the response activity of
local environmental public health specialists.

Figure 4: Casual Loop diagram detailing an archetype of Fixes that
Backfire where the increased awareness of the roles of EH in emergency
response and initial promotion of the local EH specialist into response
activities had the unintended consequence of not providing or use of
PPE. Attitudes about safety were not addressed in a systematic approach;
however funding without education, resulted in many "paper tiger
response plans".

####### ***10 Essential Environmental Health Services:***

![](media/image3.png){width="3.75in" height="3.8125in"}

Figure 5: Relationship of the core functions of public health with the
ten essential services.

Source: Public Health Functions Steering Committee (July 1995) ^1^

Operation PPE seeks to enhance several of the 10 Essential Environmental
Health Services.

*Essential Service #1 -- Monitor environmental and health status to
identify community health problems.*

*Essential Service #2 -- Diagnose and investigate environmental health
problems and health hazards in the community.*

*Essential Service #6 -- Enforce laws and regulations that protect
health and ensure safety.*

● Through safety first State and local programming ensuring that local
environmental health specialists are trained and equipped to use PPE,
the ability to investigate potential environmental and health hazards
within the community safely and without hesitation increases. Local
environmental public health specialists are on the front lines of
potential public health diseases when doing routine delivery of
environmental health services. The ability to perform this work safely
promotes more efficient delivery of services and enforcement of
ordinances and laws while reducing their risk and risk of potential
spread of disease by the investigator or responder to a public health
emergency. Regional training and injection of occupational safety
messages during State programming as part of this project starts the
process and self awareness of local environmental health concerning PPE
and the reduction of risk, to allow them to provide these essential
services.

*Essential Service #8 -- Assure a competent environmental health
workforce.*

● The competency of the State and local environmental health workforce
to safely and thoroughly perform their daily jobs and added emergency
response services, will be bolstered during this project. During the
initial awareness process, a checklist was developed to address the
basic PPE needs to the local environmental health specialist. Basic
items were identified from results of an initial resource typing survey
and will be solidified by training provided to State EH staff and the
environmental health response team (IA-EHRT). The training will be
delivered regionally within the state. Each local department will
identify their needs based on their service capacity and ability to
deliver and perform environmental health hazard prevention work, as a
result of the workshop training. The items will be purchased through
funding allowed by the CDC Cooperative grant during the 2007-2008 grant
year contract.

####### ***National Goals Supported*** 

**CDC Health Protection Goals ^2^**

This project seeks to support the Center for Disease Control and
Prevention goal of *People Prepared for Emerging Health Threats*, which
states that people in all communities will be protected from infectious,
occupational, environmental, and terrorist threats. The goal is broken
down into three components:

**Pre-event:**

• Increase the use and development of interventions.

• Decrease time needed to classify health events.

• Decrease time needed to detect and report chemical, biological, and
radiological agents.

• Improve the timeliness and accuracy of communications.

**Event:**

• Decrease time to identify causes, risk factors, and appropriate
interventions.

• Decrease time needed to provide countermeasures and health guidance.

**Post-event:**

• Decrease time needed to restore health services and environmental
safety to pre-event levels.

• Improve long-term follow-up provided to those affected by threats.

• Decrease time needed to implement recommendations from after- action
reports.

Improving the ability to safely respond and investigate health threats
due to any cause, including reduction of risk of occupational related
threats, is a key element when addressing the three event components.
Developing a safety first culture within public health allows for the
ability to perform these actions and promote among the community, the
assurance and guidance that is needed by the public. Events such as
Hurricane Katrina, magnify the need for educated and informed local,
State and Federal responders concerning PPE use and guidance for post
event actions by survivors and victims of public health emergencies. The
ability to lead by example concerning occupational safety is essential
to prevention.

**National Strategy to Revitalize Environmental Public Health Service
^3^**

Improving and creating a safety first culture where using PPE is second
nature, supports several of the goals detailed in CDC's *National
Strategy to Revitalize Environmental Public Health.*

*Goal 1 -- Build Capacity: Strengthen and support environmental public
health services at the state, tribal, territorial, and local levels.*

*Goal III -- Foster Leadership: Foster leadership to enhance
environmental public health leadership.*

*Goal V- Develop the Workforce: Promote the development of a competent
and effective environmental public health workforce.*

####### **Project Logic Model**

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

***Program Goal:*** To reduce the risk of disease and injury to local
Iowa Environmental health professionals due to the availability and
knowledge of use of PPE (Personal Protection Equipment) by creating an
occupational safety culture within local and State environmental public
health.

***Health Problem:*** The exposure to potential disease causing
pathogens transmitted via the environment or unintentional injuries
resulting from exposures is too high.

***Outcome Objective***: By September 1^st^, 2008 local environmental
health professionals' awareness and training levels will be increased.
On a statewide survey, 75 percent of all environmental health
departments in Iowa will have basic PPE to include eye, respiratory,
hearing, hand and foot protection.

***Determinant:*** The number of departments indicated by survey will
have a basic PPE cache indicated by survey results.

***Impact Objective:*** By July 30th, 2008 75% Iowa local environmental
health departments will have received awareness materials and training
regarding the importance and use of PPE while performing normal job
functions and response activities.

***Contributing Factors:***

1.  Lack of awareness and urgency on the importance, effectiveness and
    injury reduction benefits of PPE use while performing daily job
    functions including emergency response.

> 2\. Lack of occupational health safety programs available to local EH.
>
> 3 Increased involvement in local public health emergency response
> planning and mitigation strategies has caused a gap in theory vs.
> reality.
>
> 4\. Creation of local environmental health response plans.
>
> 5\. Local EH has not had accessibility to necessary preparedness
> funding as other public health entities due to not having a clearly
> defined role in emergency response or recovery activities.

***Process Objectives:***

1\. By July 30th, 2008 75% Iowa local environmental health departments
will have received awareness materials and training regarding the
critical value and use of PPE while performing normal job functions and
response activities.

# METHODOLOGY:

> ***Event:*** PPE Awareness campaign

***Activities:***

> ● Develop fact sheets and locate technical resources to be distributed
> to local EH.
>
> ● Create a train the trainer program using members of the Iowa
> Environmental Health Response Team
>
> ● Provide training to local environmental public health at six
> regional workshops
>
> ***Event:*** Direct funding to local EH from preparedness funding
> provided to IDPH via the CDC preparedness grant.

***Activities:***

> ● Attendance at regional PPE workshops as a local grant task
> performance measure.

● Attendees will receive funding to purchase identified PPE only.

***Event:***

Implement survey to all Local EH to measure PPE inventory levels.

**Activities:**

● Create electronic survey to be completed by 75 percent of all local
EH.

● Present findings on performance results in a journal article or
conference.

***Event:***

> Develop strategic partnerships with occupational health agencies and
> organizations.
>
> ***●*** Provide contact information and resources to local public
> health of occupational safety technical support and expertise via the
> Health Alert Network (HAN) and EH list serve.

####### 

# Next Steps and Expected Outcomes:

Completion of the activities explained and outlined in this project has
been progressing. The initial start dates of these activities were
delayed due to the incorporation of the activities into current federal
grant funding allowed to the Iowa Dept. of Public Health. The structure
of public health preparedness within Iowa is well established and
cohesive in nature. The best approach to reducing the occupational risks
to environmental public health must coincide with the best practices
already established and administered during prior grant funding. The
project is an initial step onto the road to well documented occupational
safety programming at the State and local level. Iowa is also undergoing
a redesign of public health initiative, and defining what every citizen
should expect from local environmental public health. The expectations
are very high and include the conclusion that local environmental public
health must be involved, and also lead when it comes to reducing
environmental public health hazards via delivering the ten essential
environmental health services within the core competencies framework.
Delivering these services and expectations including preparedness and
response functions, hinges upon safe work practices and a safety first
culture allowing the environmental public health specialist to act
without hesitation with their other response partners and local
infrastructure. Delivery of local environmental health programming by
the State incorporating occupational safety messages has not been
consistent. Raising the awareness of this issue and promotion of these
practices during regional workshops during the remainder of 2008 is a
welcomed addition to local environmental public health education and
training.

The incorporation of leading by example using a train the trainer
approach, and enabling local environmental public health specialists to
use the IA-EHRT team as mentors will establish a base of leaders in
environmental health occupational safety. The awareness training in PPE
selection, hazard awareness, and general safety concepts that the team
will obtain this year, will be invaluable t o sustaining a safety minded
local workforce. The ability to respond without hesitation due to lack
of knowledge of occupational risk must start by using a systematic
approach to addressing these issues outlined during this project.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Cory Frank***

The opportunity to participate in the third cohort of the EPHLI has been
a privilege and welcomed enhancement of my work and personal life. I
have appreciated the focus on moving away from traditional problem
solving methods to a systematic approach to environmental public health
problems. The interaction with my colleagues was invaluable to my
experience within the institute. The self assessments and development of
an individual development plan has taught me invaluable insights into my
work and personal life. Self awareness is a struggle that using the
techniques and education I gained has and will promote my abilities
within the environmental public health profession and my personal life.
Thank you to all the staff, faculty, and my colleagues who have helped
me on this journey this past year. I would like to personally thank my
mentor for not only providing me professional support during this
process, but understanding, insight, and inspiration to inspire to
greater value.

# ABOUT THE EPHLI FELLOW

Cory Frank, EHRT Coordinator, CHC

Bureau of Environmental Health Services

Division of Health Protection and Environmental Health

Iowa Department of Public Health

[Education:]{.underline} Graduated from Wartburg College in May 1991
with a B.A. in Biology

[Work Experience:]{.underline} Began employment as a Community Health
Consultant and Environmental Health Emergency Response Coordinator with
the Iowa Department of Public Health in December 2004. Cory's role also
is as the coordinator of the State of Iowa's EHRT (Environmental Health
Emergency Response Team). Cory led a team of 6 EH professionals through
an EMAC request to Louisiana in the wake of hurricane Katrina. In
addition to coordinating the IA-EHRT within the Iowa Department of
Public Health, Cory is a member of the State of Iowa Type 3 Incident
Management Team. Cory was appointed in May, 2002 as the Director of
Environmental Health for Warren County, Iowa where he oversaw, and
initiated programs to better the environment and public health for all
citizens of Warren County. Prior to his employment as a county
Environmental Health Specialist, he spent his prior career, working
within the research and development field as a clinical microbiologist
and bacteriologist. Cory is also a member of the third cohort of the
EPHLI (Environmental Public Health Leadership Institute). Cory, and
IA-EHRT, is working to expand and educate colleagues and citizens, about
the role environmental public health professionals play as essential
components during emergency response activities.

# REFERENCES

1.  Public Health Steering Committee. *Public Health in America,*
    Fall 1994. (July 1995). Available at:
    [*http://health.gov/phfunctions/public.htm*](http://health.gov/phfunctions/public.htm)

2.  CDC. Health Protection Goals Fact Sheet. Atlanta, GA. Dept. of
    Health and Human Services. (2005). Available at:
    [*http://www.cdc.gov/about/goals/default.htm*](http://www.cdc.gov/about/goals/default.htm)

3.  CDC. A National Strategy to Revitalize Environmental Public Health
    Services. Atlanta, GA. Dept. of Health and Human Services. (2003).
    Available at:
    *[http//www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf]{.underline}*

4.  Iowa Dept. of Public Health. *Environmental Health* *Resource Typing
    Survey.* Des Moines, IA. Environmental Health Services Bureau.
    (January 2007).