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Objectives. To examine commonalities and gaps in the content of local US heat action plans (HAPs) designed to decrease the adverse health effects of extreme heat. Methods. We used content analysis to identify common strategies and gaps in extreme heat preparedness among written HAPs in the United States from jurisdictions that serve municipalities with more than 200 000 residents. We reviewed, coded, and analyzed plans to assess the prevalence of key components and strategies. Results. All 21 plans evaluated incorporated data on activation triggers, heat health messaging and risk communication, cooling centers, surveillance activities, and agency coordination, and 95% incorporated information on outreach to at-risk populations. Gaps existed in the specific applications of these broad strategies. Conclusions. Practice-based recommendations as well as future areas of research should focus on increasing targeted strategies for at-risk individuals and expanding the use of surveillance data outside of situational awareness. (Am J Public Health. 2023;113(5):559–567. https://doi.org/10.2105/AJPH.2022.307217 )

Background Increasingly frequent and intense extreme heat events (EHEs) are indicative of climate change impacts, and urban areas’ social and built environments increase their risk for health consequences. Heat action plans (HAPs) are a strategy to bolster municipal EHE preparedness. The objective of this research is to characterize municipal interventions to EHEs and compare U.S. jurisdictions with and without formal heat action plans. Methods An online survey was sent to 99 U.S. jurisdictions with populations > 200,000 between September 2021 and January 2022. Summary statistics were calculated to describe the proportion of total jurisdictions, as well as jurisdictions with and without HAPs and in different geographies that reported engagement in extreme heat preparedness and response activities. Results Thirty-eight (38.4%) jurisdictions responded to the survey. Of those respondents, twenty-three (60.5%) reported the development of a HAP, of which 22 (95.7%) reported plans for opening cooling centers. All respondents reported conducting heat-related risk communications; however, communication approaches focused on passive, technology-dependent mechanisms. While 75.7% of jurisdictions reported having developed a definition for an EHE, less than two-thirds of responding jurisdictions reported any of the following activities: conducting heat-related surveillance (61.1%), implementing provisions for power outages (53.1%), increasing access to fans or air conditioners (48.4%), developing heat vulnerability maps (43.2%), or evaluating activities (34.2%). There were only two statistically significant (p ≥ .05) differences in the prevalence of heat-related activities between jurisdictions with and without a written HAP, possibly attributable to a relatively small sample size: surveillance and having a definition of extreme heat. Conclusions Jurisdictions can strengthen their extreme heat preparedness by expanding their consideration of at-risk populations to include communities of color, conducting formal evaluations of their responses, and by bridging the gap between the populations determined to be most at-risk and the channels of communication designed to reach them.

As the impacts of climate change increasingly and disproportionately affect indigenous peoples, equitable approaches to regional climate change adaptation must center the voices, needs, and priorities of Indigenous communities. Although the tribal climate change principles identify actionable recommendations to address the unique needs of Indigenous peoples in the contexts of climate change adaptation efforts undertaken at the Federal level in the United States (U.S.), there has yet to be exploration of how such principles might be applied at the regional level. Through semi-structured qualitative interviews with 18 representatives from inter-Tribal organizations and non-Tribal organizations engaged in regional climate adaptation in the U.S. Pacific Northwest, this research sought to describe challenges faced by, and opportunities available to, non-Tribal entities when engaging with Tribes on regional climate adaptation initiatives. All respondents reported high levels of motivation to work with Tribes on climate adaptation and identified several perceived benefits of integrating Tribal partnerships and indigenous ways of knowing into regional climate adaptation initiatives. Respondents underscored the need for strong, trusted relationships that respect the sovereignty and priorities of Tribal nations to guide engagement. However, non-Tribal organizations’ own capacity constraints, perceived Tribal capacity constraints, and institutional cultures rooted in colonialism and structural racism were discussed as obstacles to meaningful engagement. As such, we identify an urgent need to prioritize sustained investments in both Tribal and non-Tribal actors’ partnership capacities and climate change adaptation capabilities to place Indigenous voices and needs at the forefront of regional climate change adaptation planning and implementation.

Background As the health implications of climate change become more apparent, agencies and institutions across the United States are developing recommendations for state and territorial health agencies (S/THAs) to implement evidence-informed climate and health adaptation strategies. The CDC established the Building Resilience Against Climate Effects (BRACE) framework in 2010 to encourage local and state public health engagement in climate change adaptation. However, even after a decade of the BRACE initiative, the elements that affect the adoption and implementation of climate and health programming by S/THAs are not well understood. Methods Using an implementation science framework, this study sought to further understand and define the barriers and facilitators that determine the breadth and success of climate change and health activities undertaken by state health agencies (SHAs). We conducted focus groups with representatives from SHAs with and without climate and health programs, and analyzed data using the framework method for qualitative research. Results This study identified funding, state and agency-level prioritization, staff capability and capacity, and political will and polarization as factors that influence the readiness for implementation and implementation climate for climate and health activities. Conclusions As the impacts of climate change intensify, S/THAs will need to expand resources and capacity, and seek advocacy and assistance from external organizations in order to support the level of engagement required to strengthen climate resilience. Findings from this study have implications for public health policy and highlight potential pathways to expand support for climate and health activities in S/THAs in the U.S.

Heat is a dangerous hazard that causes acute heat illness, chronic disease exacerbations, adverse pregnancy outcomes, and a range of injuries. Risks are highest during extreme heat events (EHEs), which challenge the capacity of health systems and other critical infrastructure. EHEs are becoming more frequent and severe, and climate change is driving an increasing proportion of heat-related mortality, necessitating more investment in health protection. Climate-resilient health systems are better positioned for EHEs, and EHE preparedness is a form of disaster risk reduction. Preparedness activities commonly take the form of heat action plans (HAPs), with many examples at various administrative scales. HAP activities can be divided into primary prevention, most important in the pre-event phase; secondary prevention, key to risk reduction early in an EHE; and tertiary prevention, important later in the event phase. After-action reports and other postevent evaluation activities are central to adaptive management of this climate-sensitive hazard. Expected final online publication date for the

IntroductionAs wildfire smoke events increase in intensity and frequency in the Pacific Northwest, there is a growing need for effective communication on the health risks of smoke exposure. Delivery through a trusted source or intermediary has been shown to improve reception of risk communication messages. This is especially salient in rural and tribal communities who may be hesitant to trust information from state and federal agency sources. This study aims to identify and characterize trusted sources for smoke risk information in the Okanogan River Airshed Emphasis Area (ORAEA), a rural region of North Central Washington state that is heavily impacted by smoke from wildfires and prescribed fire.MethodsThe research team conducted a qualitative study using data collected through key informant interviews and focus groups to assess the role of various sources and intermediaries in disseminating smoke risk information. We used a consensual coding approach in NVivo Qualitative Analysis Software to sort data into preliminary categories, which were grouped into themes using a thematic analysis approach. We used member checking and iterative feedback processes with local project partners throughout the project to ensure credibility of results.ResultsThrough the analysis, we identified three themes characterizing trusted sources for smoke risk communication in the ORAEA. These themes were: (1) local and tribal sources of information are perceived as more trustworthy than state and federal government sources, (2) trustworthiness is determined by an evaluation of multiple factors, in particular, perceived credibility, quality of information, and relationship with the source, and (3) conservative political ideology and perceived parallels with COVID-19 communication influence perception of trust. Within each theme, we identified several sub-themes, which contributed additional nuance to our analysis.ConclusionThis study provides insights into which sources of information are trusted by rural and tribal community members in the ORAEA and why. Results from our study emphasize the importance of relationships and collaboration with local and tribal partners in smoke risk communication. In this paper, we discuss implications for state and federal agency practitioners and present recommendations for how to work with local and tribal partners on smoke risk communication.

Healthcare workers (HCW) who come into contact with tuberculosis (TB) patients are at elevated risk of TB infection and disease. The collection and handling of sputum samples for TB diagnosis poses exposure risks to HCW, particularly in settings where aerosol containment is limited. An alternative sample collection method, tongue swabbing, was designed to help mitigate this risk, and is under evaluation in multiple settings. This study assessed risk perceptions among South African HCW who used tongue swabbing in TB diagnostic research during the COVID-19 pandemic. We characterized their context-specific preferences as well as the facilitators and barriers of tongue swab use in clinical and community settings. Participants (n=18) were HCW with experience using experimental tongue swabbing methods at the South African Tuberculosis Vaccine Initiative (SATVI). We used key informant semi-structured interviews to assess attitudes toward two tongue swab strategies: Provider-collected swabbing (PS) and supervised self-swabbing (SSS). Responses from these interviews were analyzed by rapid qualitative analysis and thematic analysis methods. Facilitators included aversion to sputum (PS and SSS), perceived safety of the method (SSS), and educational resources to train patients (SSS). Barriers included cultural stigmas, as well as personal security and control of their work environment when collecting swabs in community settings. COVID-19 risk perception was a significant barrier to the PS method. Motivators for HCW use of tongue swabbing differed substantially by use case, and whether the HCW has the authority and agency to implement safety precautions in specific settings. These findings point to a need for contextually specific educational resources to enhance safety of and adherence to the SSS collection method.

Background App‐based drivers face work disruptions and infection risk during a pandemic due to the nature of their work, interactions with the public, and lack of workplace protections. Limited occupational health research has focused on their experiences. Methods We surveyed 100 app‐based drivers in Seattle, WA to assess risk perceptions, supports, and controls received from the company that employs them, sources of trust, stress, job satisfaction, COVID‐19 infection status, and how the pandemic had changed their work hours. Data were summarized descriptively and with simple regression models. We complemented this with qualitative interviews to better understand controls and policies enacted during COVID‐19, and barriers and facilitators to their implementation. Results Drivers expressed very high levels of concern for exposure and infection (86%–97% were “very concerned” for all scenarios). Only 31% of drivers reported receiving an appropriate mask from the company for which they drive. Stress (assessed via PSS‐4) was significantly higher in drivers who reported having had COVID‐19, and also significantly higher in respondents with lower reported job satisfaction. Informants frequently identified supports such as unemployment benefits and peer outreach among the driver community as ways to ensure that drivers could access available benefits during COVID‐19. Conclusions App‐based drivers received few protections from the company that employed them, and had high fear of exposure and infection at work. There is increased need for health‐supportive policies and protections for app‐based drivers. The most effective occupational and public health regulations would cover employees who may not have a traditional employer–employee relationship.

Objective: To assess the current state of graduate-level disaster-related curricula (i.e., Masters and Doctoral programs, degree concentrations, and graduate certificates) offered by the Council on Education for Public Health (CEPH)-accredited public health schools and programs in the US. Methods: This research reviewed, evaluated, and summarized the content of websites of all US-based CEPH-accredited schools and programs to identify disaster-related degree programs, degree concentrations and graduate certificates from April – June 2021. Results: Of 191 schools and programs reviewed, 29 (15%) offered disaster-related curricula, totaling 44 degrees and programs. Programs included Masters-level degrees and Masters/ Doctoral degree concentrations, with the majority taking the form of graduate certificates (64%). Schools that offered disaster-related curricula were clustered in eastern and Gulf states. Conclusion: Most US CEPH-accredited schools and programs do not offer graduate-level disaster-focused curricula. Of the programs offered, far fewer opportunities exist for in-depth graduate-degree level training compared to certificate-level training. Additionally, programs are constrained to certain areas of the country. Our findings suggest a need for disaster and public health emergency-related curricula development within schools and programs of public health to meet the growing needs of communities affected by disasters and emergencies.

State statutory laws serve as a vital tool for public health entities to assist communities with recovery from disasters. However, no systematic assessment has examined the content of state law addressing disaster recovery or explored if and how the public health role is discussed in state law addressing disaster recovery. This study examined public health-related requirements, authorities, and activities in state disaster recovery laws. Nexis Uni, a legal database, was used to identify codified state statutory laws that authorize or require specific state or local public health entity actions, or set conditions where public health entity actions could be authorized/required, related to disaster recovery planning, implementation, or evaluation (ie, health disaster recovery laws). Disaster recovery laws were reviewed and coded to identify health-related requirements, authorities, and activities planned for recovery. Most states (n = 47) have disaster recovery laws, and 17 states were found to have 30 codified statutory health disaster recovery laws. Half (n = 15) of identified laws require a public health liaison to or representation on a recovery committee or other organization/body working on recovery planning or implementation activities. State disaster recovery laws have limited public health requirements, authorities, and activities. Further research is needed to assess the potential public health benefits of components of state law supporting public health involvement in disaster recovery. The development and dissemination of best practices or model laws and tools to provide opportunities for public health actors to inform recovery decision making may enhance the potential for health promotion during disaster recovery.

As wildfire smoke events increase in intensity and frequency in the Pacific Northwest, there is a growing need for effective communication on the health risks of smoke exposure. Delivery through a trusted source or intermediary has been shown to improve reception of risk communication messages. This is especially salient in rural and tribal communities who may be hesitant to trust information from state and federal agency sources. This study aims to identify and characterize trusted sources for smoke risk information in the Okanogan River Airshed Emphasis Area (ORAEA), a rural region of North Central Washington state that is heavily impacted by smoke from wildfires and prescribed fire.The research team conducted a qualitative study using data collected through key informant interviews and focus groups to assess the role of various sources and intermediaries in disseminating smoke risk information. We used a consensual coding approach in NVivo Qualitative Analysis Software to sort data into preliminary categories, which were grouped into themes using a thematic analysis approach. We used member checking and iterative feedback processes with local project partners throughout the project to ensure credibility of results.Through the analysis, we identified three themes characterizing trusted sources for smoke risk communication in the ORAEA. These themes were: (1) local and tribal sources of information are perceived as more trustworthy than state and federal government sources, (2) trustworthiness is determined by an evaluation of multiple factors, in particular, perceived credibility, quality of information, and relationship with the source, and (3) conservative political ideology and perceived parallels with COVID-19 communication influence perception of trust. Within each theme, we identified several sub-themes, which contributed additional nuance to our analysis.This study provides insights into which sources of information are trusted by rural and tribal community members in the ORAEA and why. Results from our study emphasize the importance of relationships and collaboration with local and tribal partners in smoke risk communication. In this paper, we discuss implications for state and federal agency practitioners and present recommendations for how to work with local and tribal partners on smoke risk communication.

Objective: Although extreme heat can impact the health of anyone, certain groups are disproportionately affected. In urban settings, cooling centers are intended to reduce heat exposure by providing air-conditioned spaces to the public. We examined the characteristics of populations living near cooling centers and how well they serve areas with high social vulnerability. Methods: We identified 1402 cooling centers in 81 US cities from publicly available sources and analyzed markers of urban heat and social vulnerability in relation to their locations. Within each city, we developed cooling center access areas, defined as the geographic area within a 0.5-mile walk from a center, and compared sociodemographic characteristics of populations living within versus outside the access areas. We analyzed results by city and geographic region to evaluate climate-relevant regional differences. Results: Access to cooling centers differed among cities, ranging from 0.01% (Atlanta, Georgia) to 63.2% (Washington, DC) of the population living within an access area. On average, cooling centers were in areas that had higher levels of social vulnerability, as measured by the number of people living in urban heat islands, annual household income below poverty, racial and ethnic minority status, low educational attainment, and high unemployment rate. However, access areas were less inclusive of adult populations aged ≥65 years than among populations aged Conclusion: Given the large percentage of individuals without access to cooling centers and the anticipated increase in frequency and severity of extreme heat events, the current distribution of centers in the urban areas that we examined may be insufficient to protect individuals from the adverse health effects of extreme heat, particularly in the absence of additional measures to reduce risk.

The national response to the coronavirus disease 2019 (COVID-19) pandemic has highlighted critical weaknesses in domestic health care and public health emergency preparedness, despite nearly 2 decades of federal funding for multiple programs designed to encourage cross-cutting collaboration in emergency response. Health-care coalitions (HCCs), which are funded through the Hospital Preparedness Program, were first piloted in 2007 and have been continuously funded nationwide since 2012 to support broad collaborations across public health, emergency management, emergency medical services, and the emergency response arms of the health-care system within a geographical area. This commentary provides a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the strengths, weaknesses, opportunities, and threats related to the current HCC model against the backdrop of COVID-19. We close with concrete recommendations for better leveraging the HCC model for improved health-care system readiness. These include better evaluating the role of HCCs and their members (including the responsibility of the HCC to better communicate and align with other sectors), reconsidering the existing framework for HCC administration, increasing incentives for meaningful community participation in HCC preparedness, and supporting next-generation development of health-care preparedness systems for future pandemics.

Utilizing a longitudinal, observational study, grocery store health and safety controls implemented during the COVID-19 pandemic across stores in two cities were characterized. Sixteen stores between Seattle, WA (n = 9) and Portland, OR (n = 7) were visited monthly by the study team from May 2020 to January 2021, and observations of controls were recorded using a standardized checklist in REDCap. The checklist included questions on the presence or absence of controls such as physical barriers, social distancing markers, required masking of customers, cleaning of check-out stands, and closures of store areas. Descriptive analyses were conducted to determine the proportion of stores with a certain control each month. Mixed-effects logistic regression was used to explore how controls changed over time, and whether differences were observed between cities or by income of the area the store serves. Source control (e.g., mask requirements) and engineering controls (e.g., physical barriers at checkout) were the most common and consistent controls observed across stores and over the study period. Controls such as having special hours for vulnerable populations, demarcations on aisles for directionality, and cleaning check-out stands between customers varied significantly over time (p < 0.05 in the mixed-effects model). Having an employee present to clean baskets and carts, as well as physical barriers between self-checkouts, were significantly more common in stores in areas above the median income (p < 0.05 in the mixed-effects model). To best protect workers and shoppers from infectious agents, controls should be evidence-based, consistently implemented across grocery stores, and coupled with administrative practices and policies to promote worker wellbeing.

Older adults are more susceptible to adverse health outcomes during and after a disaster compared with their younger counterparts. Ageing-in-place organisations such as senior centres and Villages provide social services and programming for older adults and may support older adults’ resilience to disasters. This study examines the role of ageing-in-place organisations in building disaster resilience for older adults. Semi-structured interviews were conducted with a purposive sample of 14 ageing-in-place organisation leaders in King County, Washington in the United States of America. The sample included representatives of five government-run senior centres, seven non-profit senior centres and two Villages. Interviews were audio-recorded and professionally transcribed. We used a combined inductive and deductive approach to code and thematically analyse the data. Ageing-in-place organisation leadership recognise disasters as a threat to older adults’ health and safety, and they see opportunities to provide disaster-related support for older adults, though the type and extent of participation in resilience-building activities reflected each organisation's unique local context. Organisations participate in a variety of disaster-related activities, though respondents emphasised the importance of collaborative and communication-focused efforts. Findings suggest that ageing-in-place organisations may be best equipped to support older adults’ disaster resilience by serving as a trusted source of disaster-related information and providing input on the appropriateness of disaster plans and messages for the unique needs of older adults ageing-in-place.

Objectives Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. Design Retrospective cohort study. Setting Seattle Children's Hospital. Patients PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). Interventions None. Measurements and main results We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. Conclusions A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

In our increasingly interconnected world, the potential for emerging infectious diseases (EIDs) to spread globally is of paramount concern. Travel bans--herein defined as the complete restriction of travel from at least one geographic region to at least one other international geographic region--are a potential policy solution to control the global spread of disease. The social, economic, and health-related consequences of travel bans, as well as the available evidence on the effectiveness of travel restrictions in preventing the global spread of influenza, have been previously described. However, the effectiveness of travel bans in reducing the spread of noninfluenza EIDs, characterized by different rates and modes of transmission, is less well understood. This study employs an integrative review approach to summarize the minimal evidence on effectiveness of travel bans to decrease the spread of severe acute respiratory syndrome (SARS), Middle Eastern respiratory syndrome (MERS), Ebola virus disease (EVD), and Zika virus disease (ZVD). We describe and qualify the evidence presented in six modeling studies that assess the effectiveness of travel bans in controlling these noninfluenza EID events. We conclude that there is an urgent need for additional research to inform policy decisions on the use of travel bans and other control measures to control noninfluenza EIDs in advance of the next outbreak.

Background Extreme, prolonged wildfire smoke (WFS) events are becoming increasingly frequent phenomena across the Western United States. Rural communities, dependent on contributions of nature to people’s quality of life, are particularly hard hit. While prior research has explored the physical health impacts of WFS exposure, little work has been done to assess WFS impacts on mental health and wellbeing, or potential adaptation solutions. Methods Using qualitative methods, we explore the mental health and wellbeing impacts experienced by community members in a rural Washington State community that has been particularly hard hit by WFS in recent years, as well as individual, family, and community adaptation solutions. We conducted focus groups with residents and key informant interviews with local health and social service providers. Results Participants identified a variety of negative mental health and wellbeing impacts of WFS events, including heightened anxiety, depression, isolation, and a lack of motivation, as well as physical health impacts (e.g., respiratory issues and lack of exercise). Both positive and negative economic and social impacts, as well as temporary or permanent relocation impacts, were also described. The impacts were not equitably distributed; differential experiences based on income level, outdoor occupations, age (child or elderly), preexisting health conditions, housing status, and social isolation were described as making some residents more vulnerable to WFS-induced physical and mental health and wellbeing challenges than others. Proposed solutions included stress reduction (e.g., meditation and relaxation lessons), increased distribution of air filters, development of community clean air spaces, enhancing community response capacity, hosting social gatherings, increasing education, expanding and coordination risk communications, and identifying opportunities for volunteering. Findings were incorporated into a pamphlet for community distribution. We present a template version herein for adaptation and use in other communities. Conclusions Wildfire smoke events present significant mental health and wellbeing impacts for rural communities. Community-led solutions that promote stress reduction, physical protection, and community cohesion have the opportunity to bolster resilience amid this growing public health crisis.

This study used a health care claims data set of enrollees in commercial and Medicare Advantage insurance plans to assess the association between the June 2021 heat wave and the rates of emergency department visits in Portland, Oregon, and Seattle, Washington.

Research conducted in the context of a disaster or public health emergency is essential to improve knowledge about its short- and long-term health consequences, as well as the implementation and effectiveness of response and recovery strategies. Integrated approaches to conducting Disaster Research Response (DR2) can answer scientific questions, while also providing attendant value for operational response and recovery. Here, we propose a Concept of Operations (CONOPS) template to guide the collaborative development and implementation of DR2 among academic public health and public health agencies, informed by previous literature, semi-structured interviews with disaster researchers from academic public health across the United States, and discussion groups with public health practitioners. The proposed CONOPS outlines actionable strategies to address DR2 issues before, during, and after disasters for public health scholars and practitioners who seek to operationalize or enhance their DR2 programs. Additional financial and human resources will be necessary to promote widespread implementation of collaborative DR2 programs.

BACKGROUND AND AIM: The National Institute of Environmental Health Sciences (NIEHS) Disaster Response Research (DR2) Network is a network of collaborative investigators across the United States rep...

Looming climate change health impacts among rural communities will require a robust health system response. To reduce health inequities and promote climate justice, rural local health departments (LHDs) must be adequately resourced and supported to engage in climate change mitigation and adaptation policy and program development and implementation. In the United States, small local tax bases, overreliance on revenue from fee-based services, and limited federal funding to support climate change and health programming, have left rural LHDs with limited and inflexible human, financial, and political capital to support engagement in local climate change activities. Because of the urgent demands stemming from climate change, additional investments and supports are needed to rapidly build the capacity and capability of rural LHDs. Federal and state approaches to public health funding should consider the unique climate change and health risks of rural communities. Further, cross-jurisdictional shared service arrangements and state-level support to build rural LHDs’ technical capacity, and research on local impacts and culturally appropriate solutions, must be prioritized.

Extreme weather and climate events, such as heat waves, cyclones, and floods, are an expression of climate variability. These events and events influenced by climate change, such as wildfires, continue to cause significant human morbidity and mortality and adversely affect mental health and well-being. Although adverse health impacts from extreme events declined over the past few decades, climate change and more people moving into harm's way could alter this trend. Long-term changes to Earth's energy balance are increasing the frequency and intensity of many extreme events and the probability of compound events, with trends projected to accelerate under certain greenhouse gas emissions scenarios. While most of these events cannot be completely avoided, many of the health risks could be prevented through building climate-resilient health systems with improved risk reduction, preparation, response, and recovery. Conducting vulnerability and adaptation assessments and developing health system adaptation plans can identify priority actions to effectively reduce risks, such as disaster risk management and more resilient infrastructure. The risks are urgent, so action is needed now.

IntroductionThe exceptional production of research evidence during the COVID-19 pandemic required deployment of scientists to act in advisory roles to aid policy-makers in making evidence-informed decisions. The unprecedented breadth, scale and duration of the pandemic provides an opportunity to understand how science advisors experience and mitigate challenges associated with insufficient, evolving and/or conflicting evidence to inform public health decision-making.ObjectivesTo explore critically the challenges for advising evidence-informed decision-making (EIDM) in pandemic contexts, particularly around non-pharmaceutical control measures, from the perspective of experts advising policy-makers during COVID-19 globally.MethodsWe conducted in-depth qualitative interviews with 27 scientific experts and advisors who are/were engaged in COVID-19 EIDM representing four WHO regions and 11 countries (Australia, Canada, Colombia, Denmark, Ghana, Hong Kong, Nigeria, Sweden, Uganda, UK, USA) from December 2020 to May 2021. Participants informed decision-making at various and multiple levels of governance, including local/city (n=3), state/provincial (n=8), federal or national (n=20), regional or international (n=3) and university-level advising (n=3). Following each interview, we conducted member checks with participants and thematically analysed interview data using NVivo for Mac software.ResultsFindings from this study indicate multiple overarching challenges to pandemic EIDM specific to interpretation and translation of evidence, including the speed and influx of new, evolving, and conflicting evidence; concerns about scientific integrity and misinterpretation of evidence; the limited capacity to assess and produce evidence, and adapting evidence from other contexts; multiple forms of evidence and perspectives needed for EIDM; the need to make decisions quickly and under conditions of uncertainty; and a lack of transparency in how decisions are made and applied.ConclusionsFindings suggest the urgent need for global EIDM guidance that countries can adapt for in-country decisions as well as coordinated global response to future pandemics.

In response to wildfire-related air quality issues as well as those associated with winter wood stove use and prescribed and agricultural burning, Clean Air Methow&rsquo, s Clean Air Ambassador program established a community air monitoring network (CAMN) to provide geospatially specific air quality information and supplement data generated by the two Washington State Department of Ecology nephelometers situated in the area. Clean Air Ambassadors (CAAs) were purposefully selected to host low-cost air sensors based on their geographic location and interest in air quality. All 18 CAAs were interviewed to understand their motivations for participation, experiences using the data, challenges encountered, and recommendations for future project directions. Interview transcripts were coded, and a qualitative analysis approach was used to identify the key themes in each domain. The reported motivations for participation as a CAA included reducing personal exposure, protecting sensitive populations, interest in air quality or environmental science, and providing community benefits. CAAs used CAMN data to understand air quality conditions, minimize personal or familial exposure, and engage other community members in air quality discussions. Opportunities for future project directions included use for monitoring other seasonal air quality issues, informing or reducing other pollution-generating activities, school and community educational activities, opportunities for use by and engagement of different stakeholder groups, and mobile-friendly access to CAMN information. Limited challenges associated with participation were reported. Additional research is necessary to understand the community-level impacts of the CAMN. The findings may be informative for other rural wildfire smoke-prone communities establishing similar CAMNs.

CONTEXT Wildfire events are increasing in prevalence and intensity in the Pacific Northwest. Effective communication of health risks and actions to reduce exposure to wildfire smoke is imperative. OBJECTIVE We assessed the content of wildfire smoke risk messages from government organizations and mainstream media during a major wildfire smoke event in August 2018. DESIGN We conducted a content analysis of wildfire smoke risk information communicated by local and state government organizations and the mainstream media. SETTING Eight Washington State counties during a statewide wildfire smoke event in August 2018. MAIN OUTCOME MEASURE Leveraging the Extended Parallel Process Model and information in the existing literature on wildfire smoke and health, we assessed messages for the presence of information regarding health risk, personal interventions, administrative interventions, vulnerable populations, and trusted sources of information. Summary statistics were calculated to identify common messages about recommended interventions, vulnerable populations cited, and trusted sources of public health information. RESULTS Of the 273 identified government and media messages on wildfire smoke, the majority (71% and 66%) contained information about health risks. However, only 46% and 33% of government and media messages contained information about personal interventions to reduce risk, and 37% and 14% of government and media messages contained information about administrative interventions to reduce risk. Less than half of government and media messages (28% and 31%) contained information specific to vulnerable populations, and 58% and 46% of government and media messages contained any reference to a trusted source of information. CONCLUSIONS While information about wildfire smoke and health risks was communicated during Washington's August 2018 wildfire smoke event, there remains considerable opportunity to include additional information about interventions, vulnerable populations, and trusted sources of information. We recommend several opportunities to improve and evaluate risk communication and risk reduction before, during, and after future wildfire smoke events.

Objectives. To develop a set of indicators to guide and monitor climate change adaptation in US state and local health departments. Methods. We performed a narrative review of literature on indicators of climate change adaptation and public health service capacity, mapped the findings onto activities grouped by the Centers for Disease Control and Prevention’s Ten Essential Services, and drafted potential indicators to discuss with practitioners. We then refined the indicators after key informant interviews with 17 health department officials in the US Pacific Northwest in fall 2018. Results. Informants identified a need for clarity regarding state and local public health’s role in climate change adaptation, integration of adaptation into existing programs, and strengthening of communication, partnerships, and response capacity to increase resilience. We propose a set of climate change indicators applicable for state and local health departments. Conclusions. With additional context-specific refinement, the proposed indicators can aid agencies in tracking adaptation efforts. The generalizability, robustness, and relevance of the proposed indicators should be explored in other settings with a broader set of stakeholders.

ObjectiveThis study aimed to identify maritime transportation disruption impacts on available health care supplies and workers necessary to deliver hospital-based acute health care in geographically isolated communities post-disaster.MethodsSemi-structured interviews were conducted with 25 key informants knowledgeable about the hospital-based acute health care supply chain and workforce emergency management plans and procedures in 2 coastal communities in British Columbia. These locations were accessed primarily through maritime transportation, including one urban center and one smaller, more remote community. Interview transcriptions were thematically analyzed.ResultsCritical vulnerabilities to hospital-based acute health care delivery due to a maritime transportation disruption identified include lack of information about the existing supply chain, lack of formal plans and agreements, and limited local supply storage and workforce capacity. Measures to decrease vulnerability and enhance system capacity can be fostered to enhance acute health care system resilience for these and other geographically isolated communities.ConclusionsA maritime transportation disruption has the potential to impact the availability of hospital-based health care supplies and health care personnel necessary to deliver acute health care in coastal communities post-disaster. Multisector engagement is required to address complex interdependencies and competing priorities in emergency response. Additional research and public-private collaboration is necessary to quantify potential impacts of maritime transportation disruption on the acute health care system. (Disaster Med Public Health Preparedness. 2019;13:440-448)

Context Social media is becoming increasingly integrated into disaster response communication strategies of public health and emergency response agencies. Objective We sought to assess the content, accessibility, and dissemination of social media communications made by government agencies during a disaster response. Design A cross-sectional analysis of social media posts made by federal, state, and local government, public health and emergency management agencies before, during, and after the 2016 Louisiana floods was conducted to determine their content, accessibility, and dissemination by level of government and time relative to disaster onset. Setting Facebook and/or Twitter posts made by public agencies involved in the response to the 2016 Louisiana Flooding events (FEMA Disaster Declaration [DR-4277]) published between August 4 and September 16, 2016, publicly available online between February 21 and March 31, 2017, were included in the analysis. Main outcome measure Content: The text of each post was assessed to determine whether it contained information on provision of situational awareness; addressing misconception, actionable requests; mental, behavioral, and emotional support; and/or recovery and rebuilding resources. Accessibility: A Flesh-Kincaid grade level of each post was calculated, and information on post language, originality, hyperlinks, visuals, videos, or hash tag was recorded. Dissemination: The average number of reacts/likes, shares/retweets, and comments per post was calculated. Results Most posts contained information related to situational awareness and recovery resources. There was an increase in messages during the first week of the disaster at all levels. Few posts were made in languages other than English. Compared with state and federal posts, local Facebook posts averaged fewer reacts, comments, and shares throughout the analysis period. Conclusions Government agencies may maximize the use of social media platforms for disaster communications by establishing their social media network in advance of a disaster and by applying established guidelines on disaster social media use.

Introduction Climate change is leading to increasingly severe wildfires across the United States. Over the past several years, these events have led to extreme, persistent smoke events in several urban areas across the western U.S. However, the health impacts of smoke events on urban communities are not well understood. Impacts to physical activity, including active transportation, may be a useful proxy to understand physical and mental health effects of these events. We aimed to examine the impact of wildfire smoke events, determined by fine particulate matter concentrations and administrative reporting, on physical activity, measured by pedestrian and bicycle counts at eight city counters in Seattle, WA, USA. Methods We assessed for differences in daily average bicycle and pedestrian counts between pre-, during- and post-wildfire smoke periods for two wildfire smoke events in Seattle in the summers of 2017 and 2018. Results The 2018 wildfire smoke event significantly decreased daily average bicycle counts by 14.6–36.0% across the 8 counters, and 31.7%–45.2% across the two pedestrian counters. There were no significant changes in use during the 2017 event, with the exception of a significant decrease in counts at one pedestrian counter. Conclusions Urban physical activity and active transportation may be significantly impacted by future wildfire smoke events, with cascading public health consequences. Differences in impacts across the 2017 and 2018 events may be related to increased intensity of smoke, and/or to enhanced public health messaging by state and local agencies. Additional research is needed to better understand the impact of wildfire smoke on physical activity in urban communities, and to assess and inform public health risk communication campaigns to change behavior during these events.

Older adults are more susceptible to adverse health outcomes during and after a disaster compared with their younger counterparts. Developing community resilience, or strengthening communities to reduce the negative impacts of disasters, has the potential support older adults’ health and well-being. Community-based organizations (CBOs), such as senior centers and Villages, provide social services and programming that support aging in place and may support older adults’ resilience to disasters. This study examines CBO leadership perspectives on the role of CBOs in building disaster resilience for older adults aging in place, as well as perceived barriers and facilitators to incorporating disaster resilience activities into organizational programming. In-depth interviews were conducted with a purposive sample of staff-members of CBOs serving older adults aging in place in King County, Washington. Participants included representatives from 14 organizations that varied in size, geographic setting, organizational structure, and ethnic, linguistic, and socio-economic backgrounds of organizational members. The sample included five government-run senior centers, seven non-profit senior centers, and two Villages. Interviews were audio-recorded and transcribed verbatim. We used a combined inductive and deductive approach to code and thematically analyze the data. Results indicate that local context, leadership risk perception, collaborations, and existing services and programming influence CBOs’ willingness to engage in activities supporting disaster resilience for older adults aging in place. Findings suggest that CBOs supporting aging in place may support disaster resilience for older adults by serving as a trusted source of disaster preparedness information and tailoring disaster-related messages for an older adult audience.

Objective:Disaster research can inform effective, efficient, and evidence-based public health practices and decision making; identify and address knowledge gaps in current disaster preparedness and response efforts; and evaluate disaster response strategies. This study aimed to identify challenges and opportunities experienced by Washington State local health departments (LHDs) regarding engagement in disaster research activities.Methods:An online survey was disseminated to the emergency preparedness representative for the 35 LHDs in Washington State. Survey questions sought to assess familiarity and experience with disaster research, as well as identify facilitators and barriers to their involvement. The survey was first piloted with 7 local and state public health emergency preparedness practitioners.Results:A total of 82.9% of Washington’s 35 LHDs responded to our survey. Only 17.2% of respondents had previous experience with disaster research. Frequently reported barriers to engaging in disaster research included funding availability, competing everyday priorities, staff capacity, and competing priorities during disaster response.Conclusions:These findings can inform efforts to support disaster research partnerships with Washington State LHDs and facilitate future collaboration. Researchers and public health practitioners should develop relationships and work to incorporate disaster research into LHD planning, training, and exercises to foster practice-based disaster research capacity.

Introduction Disaster research response (DR2) is necessary to answer scientific questions about the environmental health impacts of disasters and the effectiveness of response and recovery strategies. This research explores the preparedness and capacity of National Institute of Environmental Health Sciences (NIEHS) P30 Core Centers (CCs) to conduct DR2 and engage with communities in the context of disasters. Methods In early 2018, we conducted an online survey of CC Directors (n = 16, 69.5% response rate) to identify their DR2 relevant scientific assets, capabilities, and activities. Summary statistics were calculated. We also conducted in-depth, semi-structured interviews with 16 (69.5%) CC Community Engagement Core directors to identify facilitators and barriers of DR2 community engagement. Interview notes were coded and thematically analyzed. Results Survey: While 56% of responding CCs reported prior participation in DR2 and preparedness to repurpose funding to support DR2, less than one third reported development of a disaster-specific data collection protocol, deployment plan, or concept of operations plan, participation in an exercise to test DR2 capacity, development of academic partnerships to conduct DR2, development of a process for fast-tracking institutional review board approvals for DR2, or maintenance of formal agreements with state, local, or community-based partner(s). A number of CCs reported developing or considering developing capacity in these areas. Barriers to, and tools and resources to enhance, CC engagement in DR2 were identified. Interviews: Four key components for community engaged DR2 were identified: pre-existing community relationships, responsive research that benefits communities, coordination among researchers, and coordination with community response partners. Several roles for, benefits of, and barriers to Community Engagement Rapid Response Teams (CERRT) were described. Conclusions CCs have significant scientific assets and community partnerships that can be leveraged for DR2; however, additional planning is necessary to ensure that these scientific assets and community partnerships are leveraged when disasters strike. Electronic supplementary material The online version of this article (10.1186/s12940-019-0498-y) contains supplementary material, which is available to authorized users.

Changes in levels and patterns of physical activity might be a mechanism to assess and inform disaster recovery through the lens of wellbeing. However, few studies have examined disaster impacts on physical activity or the potential for physical activity to serve as an indicator of disaster recovery. In this exploratory study, we examined daily bicycle and pedestrian counts from four public bicycle/pedestrian trails in Houston, before and after Hurricane Harvey landfall, to assess if physical activity returned to pre-Harvey levels. An interrupted time series analysis was conducted to examine the immediate impact of Harvey landfall on physical activity, t-tests were performed to assess if trail usage returned to pre-Harvey levels. Hurricane Harvey was found to have a significant negative impact on daily pedestrian and bicycle counts for three of the four trails. Daily pedestrian and bicycle counts were found to return to pre-Harvey or higher levels at 6 weeks post-landfall at all locations studied. We discuss the potential for further research to examine the trends, feasibility, validity, and limitations of using bicycle and pedestrian use levels as a proxy for disaster recovery and wellbeing among affected populations.

Recognizing the public health professional are critical members of interprofessional teams, the Council on Education for Public Health (CEPH) recently added a required Masters of Public Health (MPH) student competency focused on interprofessional education (IPE). A student-centered approach to the design and evaluation of an emergency preparedness-focused curricular program to meet the interprofessional needs of MPH students was used to meet this expectation at the University of Washington. Curriculum design was informed by two 80-minute listening sessions with MPH students to better understand their current interprofessional educational experiences and needs, and how an emergency preparedness-focused two-hour Interprofessional Active Learning Series (iPALS) session could help them develop interprofessional competency. The resultant iPALS session was assessed with a short, paper-based questionnaire. We found MPH students have an interest in participating in IPE, and that all students who participated in the emergency preparedness-focused iPALS session reported significant increases in their interprofessional and disaster response abilities based on their pre- and post-session evaluations. Student-centered IPE curriculum focused on emergency preparedness can enhance the self-reported ability of students across the health sciences to perform on interprofessional teams while engaging in a topic that has relevance to MPH students.

Disaster recovery provides an opportunity to build healthier and more resilient communities. However, opportunities and challenges encountered by local health departments (LHDs) when integrating health considerations into recovery have yet to be explored. Following Hurricane Harvey, 17 local health and emergency management officials from 10 agencies in impacted Texas, USA jurisdictions were interviewed to describe the types and level of LHD engagement in disaster recovery planning and implementation and the extent to which communities leveraged recovery to build healthier, more resilient communities. Interviews were conducted between December 2017 and January 2018 and focused on if and how their communities were incorporating public health considerations into the visioning, planning, implementation, and assessment phases of disaster recovery. Using a combined inductive and deductive approach, we thematically analyzed interview notes and/or transcripts. LHDs reported varied levels of engagement and participation in activities to support their community&rsquo, s recovery. However, we found that LHDs rarely articulated or informed decision makers about the health impacts of recovery activities undertaken by other sectors. LHDs would benefit from additional resources, support, and technical assistance designed to facilitate working across sectors and building resilience during recovery.

A growing body of literature suggests that restrictive public health measures implemented to control COVID-19 have had negative impacts on physical activity. We examined how Stay Home orders in Houston, New York City, and Seattle impacted outdoor physical activity patterns, measured by daily bicycle and pedestrian count data. We assessed changes in activity levels between the period before and during Stay Home orders. Across all three cities, we found significant changes in bicycle and pedestrian counts from the period before to the period during Stay Home orders. The direction of change varied by location, likely due to differing local contexts and outbreak progression. These results can inform policy around the use of outdoor public infrastructure as the COVID-19 pandemic continues.

ObjectiveWe aimed to quantitatively gauge local public health workers’ perceptions toward disaster recovery role expectations among jurisdictions in New Jersey and Maryland affected by Hurricane Sandy.MethodsAn online survey was made available in 2014 to all employees in 8 Maryland and New Jersey local health departments whose jurisdictions had been impacted by Hurricane Sandy in October 2012. The survey included perceptions of their actual disaster recovery involvement across 3 phases: days to weeks, weeks to months, and months to years. The survey also queried about their perceptions about future involvement and future available support.ResultsSixty-four percent of the 1047 potential staff responded to the survey (n=669). Across the 3 phases, 72% to 74% of the pre-Hurricane Sandy hires knew their roles in disaster recovery, 73% to 75% indicated confidence in their assigned roles (self-efficacy), and 58% to 63% indicated that their participation made a difference (response efficacy). Of the respondents who did not think it likely that they would be asked to participate in future disaster recovery efforts (n=70), 39% indicated a willingness to participate.ConclusionThe marked gaps identified in local public health workers’ awareness of, sense of efficacy toward, and willingness to participate in disaster recovery efforts after Hurricane Sandy represent a significant infrastructural concern of policy and programmatic relevance. (Disaster Med Public Health Preparedness. 2016;10:371–377)

Translation strategies are critical for sharing research with public health practitioners. To disseminate our analyses of legal issues that arise relative to mental and behavioral health during emergencies, we created 10 brief translational tools for members of the public health workforce. In consultation with an interdisciplinary project advisory group (PAG), we identified each tool's topic and format. PAG members reviewed draft and final versions of the tools. We then worked with local health departments throughout the country to distribute the tools along with a brief survey to determine practitioners' perceived utility of the tools. Through survey responses, we learned that practitioners believed the tools provided information that would be useful during the planning, response, and recovery phases of an emergency. This article describes the creation of the PAG, the development of the tools, and lessons learned for those seeking to translate legal and ethical research findings for practitioner audiences.

Objective: Horizontal intergovernmental coordination, or interlocal collaboration, is an ongoing strategy to enhance public health emergency preparedness in the United States. This study aims to understand the impact of interlocal collaboration on emergency preparedness, and how the Urban Area Security Initiative (UASI) program, a federally administered grant program to promote regional preparedness capability development, has influenced perceptions of this relationship. Design: Semistructured interviews were conducted and recorded in early 2014. Transcribed data were coded and iteratively analyzed. A purposive and snowball sampling strategy was used. Setting: Interviews were conducted in person or by phone. Participants: Twenty-eight key informants were interviewed during 24 interviews. Individuals were selected as key informants due to their knowledge of a UASI region(s) and its governance structures, investment strategies, and challenges, as well as knowledge of the UASI program’s history and goals. Main outcome measure(s): Interviews were used to identify, describe, and characterize perceptions of interlocal collaboration, national emergency preparedness, and the UASI grant. Results: Impacts, challenges, incentives, facilitators, and disadvantages to interlocal collaboration were identified. Interlocal collaboration was found to impact preparedness by promoting the perceived dissolution of geopolitical boundaries; developing self-reliant regions; developing regional capabilities; promoting regional risk identification; and creating an appreciation of interlocal collaboration importance. The UASI program was thought to have a profound and unique impact on the development of interlocal collaboration infrastructure and on national preparedness. Conclusions: Interlocal collaborations contribute to overall national preparedness. Grant programs, such as the UASI, can incentivize and foster interlocal collaboration in preparedness.

Background: As climate change is expected to result in more frequent, larger fires and associated smoke impacts, creating and sustaining wildfire smoke-resilient communities is an urgent public health priority. Following two summers of persistent and extreme wildfire smoke events in Washington state, the need for additional research on wildfire smoke health impacts, risk communication, and risk reduction, and an associated greater coordination between researcher and practitioner communities, is of paramount importance. Objectives: On 30 October 2018, the University of Washington hosted a Wildfire Smoke Risk Communication Stakeholder Synthesis Symposium in Seattle, Washington. The goals of the symposium were to identify and prioritize practice-based information gaps necessary to promote effective wildfire smoke risk communication and risk reduction across Washington state, foster collaboration among practitioners and academics to address information gaps using research, and provide regional stakeholders with access to the best available health and climate science about current and future wildfire risks. Methods: Seventy-six Washington state practitioners and academics with relevant professional responsibilities or expertise in wildfire smoke and health engaged in small group discussions using the &ldquo, World Caf&eacute, Method&rdquo, to identify practice-relevant research needs related to wildfire smoke and health. Notes from each discussion were coded and qualitatively analyzed using a content analysis approach. Discussion: Washington state&rsquo, s public health and air quality practitioners need additional evidence to communicate and reduce wildfire smoke risk. Exposure, health risk, risk communication, behavior change and interventions, and legal and policy research needs were identified, along with the need to develop research infrastructure to support wildfire smoke and health science. Practice-relevant, collaborative research should be prioritized to address this increasing health threat.

Introduction: Interlocal collaboration, or collaboration among neighboring independent municipalities, has been generally accepted as an emergency preparedness strategy. In the absence of large-scale disasters, emergency preparedness exercises may serve to test the effectiveness of interlocal collaboration on emergency preparedness. However, the use of emergency preparedness exercises to enhance or assess interlocal collaboration, or its impact on preparedness, requires additional empirical exploration. Hypothesis / problem: This exploratory study aims to understand the perspectives of key informants (KIs) with broad knowledge of the history, goals, and implementation of the Urban Area Security Initiative (UASI) program, as well as knowledge of interlocal collaboration exercises conducted as part of the UASI program, about the role of exercises in improving and assessing interlocal collaboration for emergency preparedness. Method: In early 2014, 28 KIs were interviewed during 24 semistructured interviews. Interviews were recorded and analyzed to identify key themes related to emergency preparedness exercises and the enhancement and assessment of interlocal collaboration. Results: KIs perceived exercises to enhance interlocal collaboration in preparedness by promoting regional, interlocal: risk assessment; emergency plan testing and operationalization; relationship development; support for regional plans and operational structures; capability delivery practice; best practice sharing across interlocal collaborations; and engagement of elected or senior leadership in interlocal preparedness endeavors. Exercise participants, scenarios, administration, formats, and assessment strategies to promote interlocal collaboration were identified. Conclusions: Seven distinct mechanisms by which exercises can enhance interlocal collaboration that can be used to guide future research and policy development were identified. The format, scenario, participation, and administration of emergency preparedness exercises can be tailored to enhance collaboration.