Communicating During an Emergency: Cyanotoxin Lessons From Oregon

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, how a water contamination emergency caused by cyanotoxins quickly becomes a public information emergency and the lessons for those working in public health.

LILLIAN SHIRLEY:
Our mantra for environmental health crises consistently is to communicate, you know, good risk communication. First, communicate what we know, and then communicate what we don't know, and then tell people what we're doing about it.

CURTIS CUDE:
There are so many uses for water in our world, and we spent a fair amount of time developing public health messaging around all those possible uses.

KARI SALIS:
We had to learn quickly what's going to work. Like, people are asking lots of questions about all these uses of water. Is this okay? Is that okay?

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, exploring the lessons learned from a threat to Salem, Oregon's drinking water in 2018, cyanotoxins making their way to the city's water supplies fueled by bacteria growing and spreading in the summer heat.

The threat to Salem, Oregon's drinking water supply two years ago was a public health emergency, but it was a public information emergency as well. Our guests on this episode worked the case and spent time afterward evaluating the lessons learned.

Lillian Shirley is public health director of the Oregon Health Authority. Curtis Cude is Oregon's environmental public health surveillance program manager. Kari Salis is the department's drinking water services technical services unit manager.

Kari begins our conversation explaining the difference between cyanotoxins and cyanobacteria.

SALIS:
Well, I'm going to start with cyanotoxin. So, cyanotoxins are, as you might guess, a toxin that is harmful to humans and animals, and they're produced by a cyanobacteria which can be present in source waters, surface waters around the country. They thrive in situations with stagnant water, high temperatures, nutrients such as nitrogen and phosphorus.

And these cyanobacteria can bloom under ideal conditions and that's when the toxins can be produced. And these toxins can find their way not only for users using the water recreationally, but also flow downstream to intakes of public water systems.

JOHNSON:
Kari, why then should we be concerned about cyanotoxins and cyanobacteria? What's the big deal?

SALIS:
Well, they can have a significant health effects, particularly with vulnerable populations such as children, but also to pets.

Cyanotoxins can cause abdominal pain, vomiting, diarrhea, and also it can cause liver and kidney damage. So, they can have severe consequences if it's ingested or inhaled, and also some skin contact can cause dermatitis.

So, it's definitely something we want to be concerned about.

JOHNSON:
In 2018, there was a problem with this sort of contamination in the city of Salem.

Director Shirley, can you tell us what happened there?

SHIRLEY:
Sure. Well, the city of Salem is actually Oregon's state capital, and it draws its drinking water from the North Santiam River. And that's fed by a body of water known as the Detroit Reservoir, 46 miles southeast of the city.

So, in 2018, the city experienced a threat to its finished drinking water from toxins produced by this bloom in the reservoir, also known as a harmful algae bloom.

This is not unusual in Oregon in the heat of the summer in different bodies of water throughout this state, particularly in our wild forest land. The significant thing here—it made its way to the finished drinking water.

So, as Kari pointed out, you know, they are concerning. They can cause illness in humans and animals in many different ways, and the city's drinking water levels were detected just above the EPA's drinking water advisory levels for vulnerable people. So, in other words, it wasn't a generic threat across the population.

But what we experienced here in Oregon—which is something that public health agencies face a lot when there is a threat, whether it's air quality or drinking water quality—what happened was infants, particularly those that are formula-fed, children five and under, and pregnant and nursing women, and people with pre-existing living conditions or those receiving dialysis treatment are particularly at risk at these kind of micro levels.

However, the city's entire population were alerted and became increasingly concerned and frightened about their exposure to the cyanotoxins. So, through pathways ranging from misting of food in grocery stores, a food processing plant that was in the area, and hospitals were all afraid to use the effected water.

And I think that even above and below the science that we would respond to as public health practitioners, we had to respond to this emergency, which was really a public information emergency.

JOHNSON:
So, Curtis, people were afraid the food was being contaminated?

CUDE:
Right. I mean, there are so many uses for water in our world, and we spent a fair amount of time developing public health messaging around all those possible uses and trying to address people's concerns about consuming food products that had used that water.

And, as Director Shirley mentioned, it was a huge communications challenge.

JOHNSON:
Kari, it sounds as though you had to speak a lot of people as soon as possible.

SALIS:
Yeah. I mean, one of the things—like, just going with what we're talking about—is working with our licensing agencies.

So, we have agencies, usually at the county health department, that license restaurants, for example. Also, we have in Oregon the Department of Agriculture that licenses food processors, as well as the grocery stores that mist the broccoli and that sort of thing.

So, we had to come up with policies for restaurants, protocols that they could use to remain open if they chose and also for the grocery stores and food processors, protocols that they could follow to also ensure that their customers were safe.

For the grocery stores, we basically posted signs. We had the grocery stores post signs to indicate that the food was misted with this water and that it was still safe to consume because it's a relatively small amount.

For processors that had a significant portion of water in their product, such as soup or popsicles, we did advise them perhaps not to produce during that time.

SHIRLEY:
Right. And so, back to your question, our mantra for environmental health crises consistently is to communicate, you know, good risk communication. First, communicate what we know, and then communicate what we don't know, and then tell people what we're doing about it, even if we have to say at that moment, "We're figuring out what to do about it."

But, you know, be first and provide early public notification of the crisis and try and get those science-based health messaging out to reduce public anxiety, like ahead of social media, ahead of the text messaging that was going out from the emergency command center.

So, in the 2018 crisis around cyanotoxins in the drinking water, we really mobilized first to share information quickly and broadly across agencies and effected groups.

And listening to Kari's kind of story—you know, usually we think of partnerships, you know, like federal public health, state public health, county and city public health.

But what we realized, you know, some of our major partners in getting control of the messaging and getting the confidence and trust of the public in the region was the department of agriculture—it was the city and county emergency managers, it was the districts—that was responsible, another governmental agency outside of city and county and outside of public health that was responsible for the drinking water area.

So, you know, really preparing early to understand what is the impact of those partnerships.

JOHNSON:
Well, let's talk about that.

Was it a challenge in and of itself? How easy is it to actually tackle a contamination outbreak like this?

SALIS:
Yeah, I can jump in here. So, Salem used a filtration process followed by chlorination.

And so, the first step to combat this toxin was to increase their chlorine and the amount of time that the chlorine had with the toxin. That's the easiest thing to do.

And then, looking at some other optimization of their filtration system. Ultimately, within probably the quickest time ever, the city of Salem was able to install powdered activated carbon, which can help the toxins kind of attach to the carbon and ultimately be filtered out. So, they were able to get that up and running in a shocking two-week time period.

Ultimately, their long-term plan is to install ozonation, which will also remove the toxin.

JOHNSON:
Can you talk about that time to respond?

In a situation like this, from cooking to popsicles, water is a big deal for people, you know. You don't have a lot of time.

You had to move fast, both on the solution and the cleanup, but also on the education. What was that like, Kari?

SALIS:
Well, it was very stressful.

I want to point out that cyanotoxins are not a regulated contaminant. So, our drinking water programs around the country are used to dealing with regulated contaminants. Those are very well-thought-out, they have maximum contaminant levels, we know how to treat for them, everything has been well-studied and well-established.

For cyanotoxins, we're just in the early stages as a nation of getting to that point. And so, it's considered an unregulated contaminant. Luckily, the Environmental Protection Agency does have some health advisory levels established for microcystins and cylindrospermopsin.

And so, when we first heard about it, like Lillian pointed out, this was the first time we've ever seen cyanotoxins in treated water in Oregon. And it, of course, it happened on Memorial Day weekend.

So, we, of course, first looked at EPA, looked at their health advisory levels. And, you know, we talk about being prepared and talking about the science, but I guess I also want to point out that sometimes the science is confusing and the agencies need to step up and interpret that science for the public.

In this case, the health advisory level for both microcystins and cylindrospermopsin were a 10-day health advisory. So, according to the EPA, vulnerable people, infants drinking baby formula, would be okay to drink this water for 10 days. But somehow on the 11th day, it's not good.

So, this is something the public could just absolutely not accept. But again, it was new to us. So, we started out talking about the EPA health advisory and we pretty quickly realized this was not going to fly. We need to come up with a clear, understandable message for people. What should these moms feed their babies?

And so, that was a learning lesson for us, for sure. You know, we had to learn quickly what's going to work. Like, people are asking lots of questions about all these uses of water. Is this okay? Is that okay? Surgeries were being postponed until we had the answer of what they should do with their medical equipment.

So, we were needing to reach out to our partners—our federal partners at EPA, experts at universities who have studied these topics—and kind of gather the information, condense it into something that was acceptable, usable, digestible to the public. And that would help instill, if not confidence in their drinking water, at least actions they could take to protect themselves and their family.

JOHNSON:
What has the state done to prepare itself, then, against future outbreaks like this, Director Shirley?

SHIRLEY:
I think we've come up with four major lessons learned.

One is, as we talked about earlier, develop partnerships and don't necessarily develop partnerships according to what you thought for the last event, because this event is new and you've got to make sure that that happens.

And those partnerships—there's strong planning with partners from the beginning, and we definitely saw that with the county commissioners, the city of Salem councilors, as well as the drinking water board.

And again, as Kari pointed out, consistent messaging was really important, and saying what we knew and what we didn't know.

And I think what our biggest lessons from that is to continuously scan for emergent issues. Emerging issues, you know, are all out there. We know we've been blindsided by some of them recently.

As an example, we do a lot of work around wildfire preparation with the forest service and with making sure we do asthma surveillance or emergency rooms surveillance.

But these wildfires—for the first time in Oregon, we realized structures were burning. You know, whole cities were burned, electrical power plants were burned, including a couple of places' drinking water infrastructure. So, those toxins are now in the smoke that we have to protect for and not just, you know, traditional wildland fire smoke. So, that's an example of scanning for emergencies.

Convene a team. We've convened a team here when we've identified an emerging issue that isn't here yet, but we know, unfortunately, is on the horizon and how can we mitigate it if it does get here.

So, we've designated within our own department subject matter experts within the agency to do this essential messaging that Kari and Curtis pointed out is so important, but also to help us look at what is the guidance and what's the current science before a crisis.

And one example in real time I can give you that we're doing that now for PFAS, which is out in the horizon in our environmental concerns even though our state hasn't been identified as having a significant source of exposure, to the public, of PFAS in Oregon.

So, that's the idea of scan for emergency issues, develop those partnerships, and convene a team to be ready for it.

And then—I can't emphasize enough how important it is to cross-train in incident command. You know, right now we are running three joint incident command structures simultaneously, which is unified command.

And just really going deep, not just in, you know, the health preparedness and emergency sections of our departments at the state, but across lots of different agencies. You know, like, start out with a coalition of the willing.

You know, there are people who have risen to the occasion. We had people running a logistics section, for instance, that were executive assistants that have real natural ability once they're trained in that, to be able to do that.

But these are complex issues, and we need individuals trained with very different disciplines.

JOHNSON:
Are there any other new methods, tools, or technologies that could help you forecast and manage future cyanobacteria outbreaks?

SALIS:
Yeah, I mean, in terms of cyanotoxins, it is still pretty new. So we, ideally, would like to find an indicator of these toxins, so how will we know when the toxins might be developing upstream, so we get a little bit of a heads up, if you will. And then the operators of these filter plans can work towards optimizing their filtration process in any way possible.

So, there is something called qPCR—which is a quantitative polymerase chain reaction method—which basically looks at whether the cyanobacteria that's present has the genes that would enable them to produce the toxin. So, it's called qPCR, and we're looking at qPCR testing to see how it correlates with the cyanotoxin.

JOHNSON:
I've heard satellite imagery might be useful. Are you thinking about that too?

CUDE:
Yes, actually.

We started working with something called CyAN, which is the Cyanobacteria Assessment Network—that's a multi-agency project that includes EPA, the U.S. Geological Survey, NASA, and the National Oceanic and Atmospheric Administration—and what that's allowing us to do is to get a satellite view of the entire landscape of larger water bodies and see what the cyanobacteria levels might be in those water bodies.

And what that could allow us to do is to direct monitoring resources or, in the future, just directly place public health advisories on those water bodies.

Now, that depends on us understanding the relationship between cyanotoxins and cyanobacteria in those particular water bodies, because just because you have cyanobacteria in a water body does not equate to harmful levels of cyanotoxins.

So, we want to be careful, and selective, and conservative about where we place those public health advisories. But at the same time, we want to exercise due caution and make sure that people are protected for recreation.

This network—this satellite system—might be useful for doing this advanced monitoring and notification, but it also allows us to go back in time to 2003, and begin to answer the questions that people pose to us about harmful algae blooms. People are usually asking us, "It seems like these harmful algae blooms are getting worse over time. What can you tell us about that?"

This satellite data will be able to provide us those types of answers about how often, how intense those blooms are, where are they distributed throughout space, are they moving more northward? You know, we have a lot of theories about the change in harmful algae blooms, and this CyAN data might help us start to answer those questions.

JOHNSON:
What's the best argument for tackling this issue before it becomes a problem, Curtis?

CUDE:
Well, I think the strongest argument for taking cyanotoxin seriously is that it can harm your health. You know, in large enough levels it can pose an acute and immediate health outcome. And we've seen that with domestic animals, in dogs and livestock.

And while people can become sick right away, or within a couple of days, we also know that long-term exposure to cyanotoxins can lead to things like kidney and liver damage.

JOHNSON:
Kari?

SALIS:
I guess I would just say that these threats can be unknown because they're unregulated. Water systems are not required to monitor for them.

In Oregon, we've had a voluntary monitoring program for roughly 10 years, and I'm talking about public water system intakes. So, we have systems that want to kind of go above and beyond, analyzing to see if they have any toxins in their water, but not everyone is doing that.

And when we created regulations in 2018, we looked at susceptible sources and we basically required all susceptible sources to monitor. And we think that that allowed for increase of public confidence because not only was Salem was affected, but other communities were maybe wondering if this was in their water.

And so, by monitoring for this as a requirement, it can help with public confidence. And then, we had kind of a pathway laid out, so it took out the guessing work for water suppliers and it just made it a little bit more known as to how to respond.

JOHNSON:
Director Shirley, at the executive level, what's the best argument for leadership taking on this challenge?

SHIRLEY:
Well, it's a growing and emerging threat. It's part of the quilt that we're seeing with a changing climate—everything from increased weather events, etc.

And our job—again, back to how do we simplify what's our framework. It is our job to protect our populations, to prevent bad things from happening to them, and to contain things that are emerging to threaten their health.

So, I would say protect, prevent, and contain should lead to policies and procedures, that we have to be looking towards the horizon around, and how do we apply good, solid science and public health practice in that framework for things that we're learning.

JOHNSON:
You can find links to resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And, if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org. That's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.