Dean, Brandon MPH; Bagwell, Dee Ann MA, MPH; Dora, Vinita MPH; Khan, Sinan MPH, MA; Plough, Alonzo PhD, MPH
All communities face a broad range of natural and manmade hazards that can threaten the safety and health of the public. While different communities face different sets of known and unknown threats, knowledge about a possible threat does not always translate into action, for example, setting preparedness goals, developing sound preparedness, response, and recovery plans, and establishing metrics for measuring performance and identifying areas of improvement.1–3 Deciding which hazards to plan for can be daunting to a jurisdiction, as priorities can be influenced by headlines, available grants, and politics.
Since 2006, public health preparedness efforts have been guided by an “all-hazards” approach to preparedness and response.4 However, without a strategy for prioritized hazard-specific planning, all-hazards preparedness can lead to poor metrics and diminished response capabilities, particularly for high-impact and complex health emergencies.5 Risk assessments have long been used to provide the foundation for effective emergency preparedness planning.6,7 While often exceptionally robust, the conventional assessments traditionally focus on infrastructure and economic consequences, with very little—if any—focus on the potential health and medical impacts of the considered threats.8 This gap in understanding and quantifying hazard-specific health outcomes limits the ability to achieve improved health preparedness and response capabilities at the federal, state, and local levels.
Recent federal health preparedness guidelines underscore the important role risk assessments have in establishing jurisdictional planning priorities.9–11 As part of this new capability framework, the Centers for Disease Control and Prevention initiated a risk-based pilot project with health agencies in the 10 highest-risk metropolitan statistical areas (MSA)—including Los Angeles—to identify promising risk assessment practices throughout the country. A steering committee with representation from the Los Angeles County, Orange County, Long Beach, and Pasadena health agencies was formed to develop the Health Hazard Assessment and Prioritization (hHAP) tool and administer the process through the summer of 2013. The Los Angeles-Long Beach-Santa Ana MSA is a very large and complex area. It encompasses nearly 15 million citizens living in 122 cities and includes more than 120 hospitals and hundreds of medical and health clinics.
Each of the participating local public health agencies had previous experience with various risk assessment tools. Standard hazard assessments were conducted in 2005 and 2010, by the Los Angeles and Orange County emergency management offices as required by the Federal Disaster Mitigation Act of 2000,12 but most of the recommendations focused on defining response roles and communication strategies rather than hazard prioritization and impact mitigation. A follow-up assessment was also conducted in Los Angeles County in 2007, and while somewhat useful, the results were mostly skewed toward recent high-profile (tsunami, train accident) and high-probability (wildfires, earthquakes) events. Absent in each of these efforts was a clear and specific assessment of the potential impact on the public's health.
Relationship of Risk
Although risk assessment is standard practice throughout the emergency preparedness field, there is no standard method to define or quantify risk.13–15 The term “risk” denotes the net result of a perceived relationship between a threat or hazard and some associated vulnerability in the affected population, although that relationship and association are not strictly arithmetic.16–18 The range in potential risk definitions results in muddled analysis when trying to isolate and compare and plan for the health impacts across different hazard scenarios. In determining risk, the frequency or probability of a hazard's occurrence is consistently overvalued, and as a result, events with minimal health-related impacts (eg, wildfires) are prioritized above events with lower probability, although greater potential impact to health and health systems (eg, pandemic influenza).3,5 Determining the appropriate health risk associated with these low-probability, high-impact hazards is challenging due to limited historical experience and wide range of possibly catastrophic outcomes.18
Project Design and Method
The primary objective of this project was to develop an effective, health-focused assessment tool to explore, define, and compare hazards and associated health vulnerabilities across the greater Los Angeles area. The Los Angeles County Department of Public Health began developing the tool in 2011—with input from the project steering committee—following receipt of risk-based project funding from the Centers for Disease Control and Prevention Public Health Emergency Preparedness cooperative agreement in that same year. After a period of extensive research, literature review, and conceptual design, the hHAP tool was completed in the summer of 2012. The assessment process began in the fall of 2012 and concluded in the winter of 2013. In addition, the California Department of Public Health's Emergency Preparedness Office adopted and disseminated the hHAP tool to 51 county and municipal health agencies throughout the state during the summer of 2012.
The hHAP tool uses a Risk Score to explore and express interdependent relationships between the various hazards. Each Risk Score is a hazard-specific, quantifiable metric resulting from the interaction of 4 primary Risk Components: (1) Hazard Probability: likelihood of hazard occurrence; (2) Health Severity: potential for hazard to result in increased morbidity, hospitalizations, and mortality; (3) Systems Impact: impact of hazard on the community's public health, medical, and mental/behavioral health systems; and (4) Community Resources: evaluation of preparedness and response resources available to emergency response and community-based agencies throughout the region to mitigate the destructive effects of each hazard. Designed for potential application by other health jurisdictions, the tool includes a prepopulated listing of 60 scenario-based potential hazards—divided into 1 of 4 hazard groups: biological, natural, chemical/radiological, and technological—each providing a realistic picture of the hazard and health-related threats to assist participants and planners in appropriately assessing of vulnerability, impact, and resources (Table 1).13,15
The specific steps necessary to successfully complete the hHAP assessment process are outlined in the Figure. The first step was to determine which of the 60 possible hazards were most relevant and appropriate for further consideration and assessment with partner agencies in the Southern California area. This initial evaluation—conducted by the project steering committee—narrowed the list of hazards down to 36 by removing those hazards with low probability of occurrence (eg, avalanche, hurricane) or marginal impact on the public's health (eg, landslide, thunderstorm). This remaining list of 36 hazards constituted the range of potential hazards used throughout the remaining assessment process. The probability and health severity of each of the 36 hazards were then each determined by a team of public health preparedness subject matter experts from each of the 4 participating public health agencies. Next, through a series of 3 separate assessments with public health, medical, and behavioral health subject matter experts, the impact of each hazard on the public health, medical, and mental/behavioral systems was determined. These 3 Risk Components constitute the hazard-specific vulnerability. Finally, to determine the preparedness and response resources available in the first responder and community-based agencies, another series of community-based focus groups were convened to assess the level of hazard-specific preparedness and readiness capacities. Each assessment included numerous representatives from various and unique agencies, each specific to the particular assessment and independent from previous or later assessment meetings. The mean score from each of these assessment meetings provides a Risk Component value that is used to calculate the final hazard-specific Risk Score. Each Risk Score is a representation of the total health and medical risk of the identified hazard, which can be sorted and ranked by each participating jurisdiction and agency to more effectively prioritize future planning and preparedness activities.2,5
The hHAP tool and method presents a unique, simple, and flexible tool for state and local health agencies to improve their ability to effectively conduct a hazard assessment process. The tool incorporates key elements from existing assessment tools,20,21 with a health and medical assessment feature and community-focused engagement method to both focus and expand the ability of the assessment process to understand the critical relationship between hazard, health, and community, improve the effectiveness of response interventions, and improve accountability in state and local preparedness programs.4,22
Whole Community Engagement
While government bears a large part of responsibility to prepare for and respond to disasters, effective planning for public health emergencies cannot happen without the focused and systematic engagement of local response and community-based stakeholder agencies.23,24 Many of the inherent challenges with risk assessment stem from the social nature of vulnerability that varies by hazard as well as by community perception.25 These challenges are further magnified in communities as large, complex, and diverse as those in Los Angeles. The hHAP method was developed to facilitate increased and improved engagement across health, governmental, and community-based agencies and sectors, a very different approach used by previous assessment methods.20,21,26 As noted, the tool requires a minimum of 5 separate and independent targeted focus group engagements of various local governmental and community-based agencies to complete the assessment.
Expanding the process beyond traditional public health departments to include medical and mental/behavioral health agencies, emergency management, as well as local law and fire agencies, ensures a broad based health and emergency response understanding of risk: impacts, vulnerabilities, and mitigation resources.22 The inclusion of community- and faith-based agencies and partners engages relevant and appropriate, although historically nontraditional, planning partners into the governmental planning process that makes operational a whole of community planning strategy.23 Effective community engagement—although challenging to both plan and execute—provides a foundational mechanism to identify the public and community perspectives and concerns, as well as include existing resource capabilities into the traditional planning process, a critical step in the process toward effectively leveraging social networks and other nontraditional community assets and resources during an emergency response.27
Results and Application
This report highlights the key objectives, features, and preliminary results of this in-progress assessment project. The initial assessment for the entire MSA was completed in February 2013 and includes complete data on 3 of the 4 Risk Components: Hazard Probability, Health Severity, and Systems Impact. However, because of the size and complexity of communities within Los Angeles and Orange counties, further community-based outreach and engagement sessions are planned throughout the spring of 2013 to further enhance and complement the Community Resources Risk Component, beyond the 2 assessment meetings held in early 2013. This continued focus on community-based interaction reflects the commitment to and value of including nontraditional stakeholders in the iterative planning process. Final results for the Los Angeles-Long Beach-Santa Ana MSA will be available in June 2013. And although in the final stages of completion, the Risk Score results thus far provide a preliminary comparison of perceived risk in the Los Angeles area, particularly when compared with the initial results from the California Department of Public Health's statewide assessment, which reflect the priorities of a large and diverse state (Table 2). Initial results from the Southern California MSA reveal the effects of this health-centric method at a more local perspective.
In Los Angeles County, the prioritized results will be evaluated against new federal preparedness capabilities to match each hazard-specific risk with particular tasks, planning elements, and initiatives in order to achieve measurable preparedness and response metrics.2,10,11 In addition to aligning with federal initiatives and grants, hHAP results could also be used to analyze existing imbalances between funding streams and jurisdictional priorities, develop evaluation plans to measure risk reduction over time, and provide a basis for ongoing community engagement. As noted, the California Department of Public Health adopted and disseminated the tool to 51 county and municipal health agencies throughout the state as a required component of health agency preparedness work plans. Together, the multiple jurisdictions completing the assessment tool provide the first complete and standardized assessment of hazard-specific risks and resources linked to health consequences across California.
Like all hazard assessments, the hHAP tool is limited to some degree by the subjective nature of assessing the potential impact of future event. The inclusion of a robust community engagement feature adds significant value to both the process and outcome of this project; however, it all also requires additional time and resources to engage and capture the varied community input and voices, particularly in the large and complex Los Angeles communities. This challenge, along with the accelerated timeline of this project, prevented a completely representative engagement process of numerous potential community groups.
Public health preparedness and emergency management are more challenging with the increased frequency, scope, and scale of many natural disasters, emerging or reemerging infectious diseases, along with the potential for terrorist acts remaining a consistent threat. Public health preparedness efforts must continue to evolve to stay relevant and effective.28 Los Angeles County's hHAP tool represents an innovative adaptation of standard emergency management practice that offers several benefits. The health-specific focus provides health officials and agencies with a practical mechanism to explore the complex relationship between hazards and health outcomes.8 The addition of a community engagement component greatly improves the capability to develop response plans that are more inclusive of both community resources and needs, key aspects in meeting the goals of community resiliency, which has emerged as a key policy issue and programmatic goal at the federal, state, and local levels.24 Finally, designed to be both simple and flexible, the hHAP tool can be used, adapted, and incorporated by any health department regardless of resource limitations or analytical capabilities.
While there may not be wide agreement on how risks and hazards are conceptualized and quantified,3,19 public health officials, decision makers, preparedness planners, and emergency managers must agree on the value of such assessment and collaboratively work toward a standard process for identifying, assessing, prioritizing, and mitigating risk.2,29 Methods and expertise from many research areas and disciplines previously external to public health and emergency management must be included and incorporated into this discussion and debate.13,19 An effective, health-focused process of risk and hazard assessment will improve current preparedness planning activities and support a more effective use of limited resources on activities that can improve agency response and community resilience capabilities.
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