Chapter 5: Air

5.1.

Problem-solving exercise: epidemic asthma

5.2.

Problem-solving exercise: AECI/MACASSAR sulfur fire

ANNEXES

5.1. Problem-solving exercise: epidemic asthma1

Prepared by: Ruth A. Etzel *

Time:

3 hours

Objectives:
At the end of the exercise, students will be able to:
1.

Develop a case definition.

2.

Interpret descriptive data.

3.

Construct histograms.

4.

Plot the distribution of cases.

5.

Construct 2x2 tables.

6.

Calculate risk ratios (odds ratios).

7.

Identify intervention strategies for prevention of epidemic asthma.

? Procedures:

1
*

1.

This is an unfolding exercise designed to mirror the real-life conditions of

an environmental health practitioner in the field. Students are asked to
analyse the information as it becomes available and to draw conclusions.
Students should be instructed to work page by page and not to look
ahead. Sessions for reporting back may take place after a series of
questions or at the conclusion of the entire exercise.

2.

Introduce the exercise and review its objectives. Divide participants into
small groups (4-6 people). Instruct participants to identify a chairperson
and a recorder.

3.

Distribute the exercise and review the participants' tasks.

4.

Reconvene the groups and invite a response from one group to the first
question. Ask whether other groups have any different responses.
Summarize and, if necessary, expand on the participants' responses and
proceed to Question 2. Allow a different group to initiate the discussion
and continue in this format until all questions have been answered.
Possible answers to the questions are provided below. These answers are
not all-inclusive. Instructors are encouraged to develop alternative
responses and intervention strategies that are appropriate to the local
situation.

From: Problem-based training exercises for environmental epidemiology. Geneva, World Health Organization, 1998 (revised
version, Document WHO/EHG/98.1)
Dr Ruth A. Etzel, National Center for Environmental Health, Centers for Disease Control and Prevention,
Atlanta, GA, USA
3

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

5.

Summarize the results, emphasizing key messages.

& Materials:
Problem-solving exercise (Annex 12 ), flip chart, coloured markers.

Case scenario, Part I

Barcelona is a city of 1.7 million situated on the Mediterranean Sea.
During the last week of January 1986, several physicians contacted public health authorities to report
an increase in the number of persons who had come to the emergency rooms of the four large urban
hospitals seeking medical care for acute severe asthma. Specifically, on Tuesday 21 January 1986 a
total of over 130 people had sought care at these hospitals for difficulty in breathing. Most of these
people were thought to be suffering asthma attacks. The attacks struck very suddenly and caused
such severe problems that 10% of the patients required ventilatory support and 2% died.

Question 1. What is asthma?

Asthma is a noncontagious disease of the lungs in which reversible obstruction
of the airways occurs. It is characterized by coughing, wheezing and difficulty
in breathing, often preceded by inhalation of dusts or other allergens. The
lungs are typically normal between attacks.
Question 2. Is this an epidemic of asthma? What further information do
you need?
The presence of an epidemic cannot be determined without knowing the
background rate of an illness and whether alterations in the surveillance system
have occurred recently. Review the definition of an epidemic: "The occurrence
in a community or region of cases of an illness, specific health-related
behaviour, or other health-related events clearly in excess of normal
expectancy".
In field investigations, assume that epidemics noticed by clinicians are real
epidemics until proven otherwise.
Question 3. Review of the hospital records reveals that the four hospitals
treated 288 persons with asthma during January 1986. Now can you
determine if this is an epidemic?
Not yet. You will need to get more information about the number of
emergency room visits for asthmatic symptoms during the past few months.

ANNEXES

Question 4. Develop a preliminary case definition.

A case definition is not rigid; it can be refined as more information is
obtained. A case definition should specify person, place and time. The
narrower the criteria, the fewer the cases that will be identified; the looser the
criteria, the more likely it is that some of those considered to be cases may turn
out to have other diseases.
The following case definition was developed:
"A case of asthma is a person over 14 years of age who came to one of the
four hospitals emergency rooms with wheezing, coughing or difficulty
breathing who was diagnosed by a physician as having asthma, asthmatic
bronchitis, spastic bronchitis, bronchial hyperactivity, asthmatic status or
bronchospasm."

Table 1. Number of persons over 14 years of age who presented with acute
asthma to the city's four hospital emergency rooms in the previous
year (1985).
Month

Number

Month

Number

Month

Number

January

199

May

165

September

181

February

146

June

128

October

166

March

180

July

138

November

182

April

155

August

124

December

147

Question 5. Do you now have sufficient information to determine if

there is an epidemic of asthma?
The number of cases (288) seen in January 1986 is clearly in excess of normal
expectancy. This indicates that there was an epidemic of asthma in January
1986.

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

Table 2. Number of persons over 14 years of age who presented with acute
asthma to the city's four hospital emergency rooms in January 1986.
Day Number

Day

Number

Day

Number

Day

Number

Day

Number

14

20

11

26

15

21

96

27

10

16

22

28

11

17

23

29

12

18

24

30

13

19

25

31

Question 6. Using the attached graph paper, draw a bar chart of the data
tabulated above in Table 2. What additional information does the bar
chart provide?
The shape of the bar chart suggests an outbreak with a common source. The
epidemic appears to be at its peak on January 21 (Figure 1).

ANNEXES

Figure 1. Number of persons seen in emergency rooms during January with

acute asthma, Barcelona, 1986
120

96

100

Number
of Cases

80

60

40

20

8 8
5

5 4 4 4

9 9

8
5

6 7 6 7

9
4

11

8 8 8 7
4

8
3

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

January

Question 7. What other information would be useful to characterize the

epidemic?
Person

age, sex

Time

time of day

Place

where asthma attack occurred; hospital emergency room.

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

Question 8. On the attached city map, using dots, show the geographic
distribution of the place of onset of illness (Table 3) for the 96 persons
who came to the emergency rooms with acute asthma on 21 January.
What does this distribution suggest?
This distribution (Figure 2) suggests that persons became ill with asthma
predominantly in Region 1 and Region 2 of the city, assuming that the
populations of the regions are roughly equal.

Question 9. Using the attached graph paper, draw a bar chart of the
cases by hour of occurrence (Table 3). What hypotheses are suggested?
This distribution suggests that onset of the illness peaked between 11:00 and
noon. Most persons reported onset between 10:00 and 16:00 (Figure 3). The
fact that attacks tended to occur around midday suggests that the causative
factor could derive from daytime activities (e.g. wharf loading).

ANNEXES

Table 3. Data regarding age, sex, time and place of onset of illness, for each of the persons who came
to the emergency room with acute asthma on 21 January 1986.
Age

Sex

41
28
27
40
30
19
17
40
28
49
47
29
28
38
49
59
39
40
59
41
10
27
27
20
27
18
30
48
30
29
37
38
39
40
37
41
40
37
38
38
39
39
40
15
18
70
18
50

F
M
M
F
F
F
F
M
M
M
F
M
F
M
F
M
M
M
M
M
M
F
M
F
M
F
M
M
F
F
M
M
M
M
F
M
M
M
M
F
F
M
M
F
M
M
F
M

Time of
onset
10:55
12:50
13:40
12:00
13:25
02:20
11:05
17:15
13:50
17:10
14:30
11:10
14:30
11:35
18:20
22:10
11:25
11:05
21:20
11:08
23:15
12:05
12:40
09:25
11:40
12:30
12:15
16.50
12:25
13:20
12:17
12:35
12:25
12:05
11:30
12:08
19:15
10:17
10:35
10:45
10:25
10:25
10:05
23:25
00:50
15:15
00:30
11:15

Place of
onset(Region)
4
2
2
3
2
3
2
1
2
1
1
2
2
1
3
6
1
1
3
10
7
2
2
8
2
2
2
2
2
2
1
1
1
1
1
10
6
1
1
1
1
1
1
6
3
2
7
2

40
41
28
48
29
30
27
57
28
30
29
29
50
30
41
40
57
47
58
41
48
69
40
27
47
89
49
29
19
67
40
29
78
68
19
38
48
37
49
38
40
59
60
19
20
47
67
28

M
M
F
F
M
M
F
M
M
F
F
M
M
F
M
F
F
M
M
F
F
M
F
F
M
M
F
F
F
F
F
F
F
M
F
M
F
M
M
F
F
M
M
M
M
M
M
M

Time of
Place of
onset onset(Region)
10:00
3
10:08
10
13:30
2
16:30
1
13:10
2
13:15
2
14:05
2
14:40
2
14:50
2
11:25
2
14:20
2
14:10
2
14:15
2
14:25
2
12:55
4
15:25
2
15:05
2
15:40
2
15:50
2
11:50
4
15:30
2
15:10
2
15:25
2
13:05
2
16:50
2
12:10
2
15:20
2
12:20
2
17:20
1
12:30
1
17:25
1
11:20
2
11:30
2
12:45
1
12:25
1
18:50
1
18:30
10
11:17
1
19:10
3
11:45
1
19:25
7
11:25
1
11:00
3
05:10
3
06:15
8
15:30
1
16:40
2
11:50
2

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

Figure 3. Hourly distribution of admissions

20

18 18
18

16

14

Cases

12

10
10

9
8

4 4
4

3 3
2

1
0

1 1
0 0

1
0

1 1
0

0
0

10 11 12 13 14 15 16 17 18 19 20 21 22 23

Hours of Day, 21 January

Case scenario, Part II

In your discussions with emergency room personnel, you learn that this is not the first time that the
hospitals have been overwhelmed with patients suffering from acute asthma attacks. You are told that
"asthma epidemic days" have occurred on 12 other occasions during the past two years.
Noting the clustering of asthma emergency room visits in space and time, you request data on air
pollution in the city during the past two years. For Tuesday 21 January, air pollution levels were below
normal for the city. The 24-hour average level of sulphur dioxide was 54 g/m2 and that of black
smoke was 98 g/m3. The highest hourly mean for nitrogen dioxide was 10 ppb. Twenty-four hour
pollen and spore counts were also below average for that time of year. Meteorological data showed
high atmospheric pressure and stagnancy of the air with very low wind speed.

10

ANNEXES

Question 10. What conclusions can you draw from this information?
Since the number of cases of asthma on 21 January was so extraordinary and
the air pollution levels were certainly no higher than normal (indeed, below
normal), it is reasonable to conclude that these air pollutants were not the
cause of the asthma epidemic.
Since many persons reported that they were affected in the centre of the city,
near the waterfront, you decide to find out more information about the
activities there. You learn that the following eight products were loaded or
unloaded from barges and boats in the harbour during the past two years:
coal

cotton

gasoline

soybeans

fuel oil

coffee

corn

butane.

Question 11. How would you use this information to further explore this
problem?
You might consider looking at whether any of these products were being
loaded or unloaded on 21 January 1986.
You ask for the dates on which each of these products were loaded or
unloaded from barges or boats. This information is shown in Table 4.

Table 4
Days product is handled
(Loaded or unloaded)

Days product is NOT handled

(Loaded or unloaded)

Asthma epidemic days

Asthma epidemic days

Product

NO

YES

NO

YES

Coal

196

521

Fuel oil

150

567

10

Gasoline

180

537

11

Cotton

399

318

Coffee

300

417

Corn

135

582

12

Soybeans

249

13

468

Butane

140

577

12

Question 12. Using the information in Table 4, complete the tables on

the following pages and calculate the risk ratios. Optional: calculate the
11

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

confidence interval (C.I.) for each table, using the formulas presented in
class discussion. Also, the computer software EPIINFO may be
demonstrated to calculate confidence intervals.
See attached sheets for calculations (Figure 4).
Question 13. How do you interpret the risk ratios and confidence
intervals you have calculated?
There is a strong association between epidemic asthma days and the loading or
unloading of soybeans from barges or boats. Note that the confidence
intervals for all the other products overlap 1, which indicates that they showed
no statistically significant association with epidemic asthma days.
Question 14. Now substitute a 1.0 for the 0 in cell B (soybeans) and recalculate.
The second calculation indicates what the magnitude of the relative risk would
have been if there had been at least one asthma day when no soybeans were
unloaded. Actually, asthma days occurred only on the days soybeans were
unloaded, resulting in a 0 in the B cell of the 2x2 table. This illustrates that
when one cell of a 2x2 table contains a zero, it is not possible to define (i.e. to
quantify) the risk ratio, although in this case it was unquantifiably high.
Question 15. How would you proceed from here?
It would be useful to make a visit to the waterfront to observe the loading and
unloading of soybeans from barges and boats. Does this activity occur near
Region 1 and Region 2 of the city? Does it occur at the middle of the day?
How could the cases have been exposed to the loading or unloading activities?

12

ANNEXES

Figure 4. Risk ratios and confidence intervals based on Table 4.

Unloading coal
Yes

No

Unloading corn
Yes

No

Epidemic

Yes

13

Epidemic

Yes

12

13

asthma day

No

196

521

717

asthma day

No

135

582

717

200

530

730

136

594

730

RR (95% CI) = 1.17 (0.26-4.28)

RR (95% CI) = 0.36 (0.01-2.45)

Unloading fuel oil

Yes

No

Unloading soybeans (1)

Yes

No

Epidemic

Yes

10

13

Epidemic

Yes

13

13

asthma day

No

150

567

717

asthma day

No

249

468

717

153

577

730

262

468

730

RR (95%CI) = 1.13 (0.20-4.46)

RR (95% CI) = Undefined

(5.56-Unquantifiably High)

Unloading gasoline
Yes

No

Unloading soybeans (2)

Yes

No

Epidemic

Yes

11

13

Epidemic

Yes

13

14

asthma day

No

180

537

717

asthma day

No

249

468

717

182

548

730

262

468

731

RR (95%CI) = 0.55 (0.06-2.54)

RR (95%CI) = 22.22 (3.45-991)

Unloading cotton

Unloading butane

Yes

No

Yes

No

Epidemic

Yes

13

Epidemic

Yes

12

13

asthma day

No

399

318

717

asthma day

No

140

577

717

406

324

730

141

589

730

RR (95%CI) = 0.93 (0.27-3.39)

RR (95%CI) =0.35 (0.01-2.39)

Unloading coffee
Yes

No

Epidemic

Yes

13

asthma day

No

300

417

717

305

425

730

RR (95%CI) = 0.87 (0.22-3.05)

Risk Ratio and 95% C.I. calculations were made using the EPI INFO software package, Version 5. USD, Inc., Stone
Mountain Georgia, USA, 1990.
95% C.I. are exact confidence intervals.

13

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

Case scenario, Part III

Question 16. Develop a strategy for prevention of asthma epidemics in
the city.
Once you have determined the route of exposure of the persons with asthma
to the loading or unloading of soybeans, you can take appropriate measures to
reduce that exposure. Since the soybean exposure emanates from a single
source, an engineering solution should be feasible. You should ask the
companies responsible for loading and unloading to reduce the amount of
soybean dust which is released into the air during the process. A bag filter at
the top of the silo may be a very effective way of accomplishing this.
Question 17. How would you assess the costs of this prevention strategy
compared to the costs of the emergency visits for asthma attacks?
You could find out the costs of the new bag filters and compare that to the
costs of emergency room treatment, including days lost from work,
hospitalization and drugs.
Based on: Anto JM et al. Community outbreaks of asthma associated with
inhalation of soybean dust. New England journal of medicine, 1989, 320(17): 10971102.
For further study of methodology for epidemiologic studies of asthma, the
following review article is recommended: Anto JM, Sunyer J. Epidemiologic
studies of asthma epidemics in Barcelona. Chest, November 1990 (supplement):
185s-189s.

14

ANNEXES

5.2. Problem-solving exercise: AECI/MACASSAR

sulfur fire
Prepared by Stuart A. Batterman*

Time:

Three 3-hour sessions

Objectives:
At the end of the exercise, students will be able to:
1.

List the steps in planning and coordinating responses to emergencies.

2.

Demonstrate the use of air quality standards, environmental monitoring

and modelling techniques (optional) in coordinating emergency response
strategies.

3.

Recognize the social and legal dimensions of public health decisionmaking.

? Procedures:
(Note to instructor: Parts 1 and 2 of this exercise would be appropriate for
university students in a variety of environmental health specialty areas. Part 3,
which involves dispersion modelling techniques, would be most appropriate
for engineering students. The exercise can still be effectively used if Part 3 is
deleted.)

1.

Introduce the exercise and review its objectives. Divide participants into
small groups (4-6 people). Instruct participants to identify a chairperson
and a recorder.

2.

Distribute the exercise and review the participants tasks.

3.

Reconvene the groups and invite a response from one group to the first
question. Ask whether other groups have any different responses.
Summarize and, if necessary, expand on the participants' responses and
proceed to Question 2. Allow a different group to initiate the discussion
and continue in this way until all questions have been answered. Possible
answers to the questions are provided below. These answers are not allinclusive. Instructors are encouraged to develop alternative responses and
intervention strategies that are appropriate to the local situation.

4.

Summarize the results, emphasizing key messages. The decision to

proceed to Part II should be made jointly by the students and instructor.

Dr. Stuart Batterman, Department of Environmental and Industrial Health, School of Public Health, Ann Arbor,
Michigan, USA
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TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

& Materials:
Problem-solving exercise (Annex 13), flip chart, coloured markers. Reference
documents for classroom review.

Case scenario, Part I

After several days of brush fires in the vicinity, a huge stockpile of sulfur caught fire late on a Saturday
afternoon. The stockpile site belonged to AECI, the largest manufacturer of chemicals and explosives
in South Africa.
Due to strong and persistent winds, the fire cannot be extinguished and a total of about 7000 tons of
sulfur has already burned. While the fire site is several kilometres away from large population areas,
the township of Macassar (population 40,000) is 2.5 km downwind, and many suburbs of Cape Town
(population 1.5 million) are 10-30 km distant. From about 21:00 on Saturday to 01:00 on Sunday
morning, the most intense period of burning, the prevailing winds blow to the west-north-west.
Symptoms among residents in the vicinity of Macassar increase in prevalence and intensity up to
midnight and beyond. Residents, mostly black, working class and poor, report a number of irritative
effects (e.g. burning and irritation of eyes, nose and throat, coughing, shortness of breath, chest pain,
stomach cramps and vomiting). Figure 1 shows the general area.

Figure 1. Map showing portions of Western Cape Province.

The smaller inset map shows a 6 km x 6 km region near the fire. F = fire
site; M = sites of existing continuous SO2 monitoring instruments; heavy
dots = farms visited after the fire to investigate vegetative damage; shaded
areas are mountains and/or nature preserves.

16

ANNEXES

17

TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

Question 1. What happens when sulfur burns? What are appropriate

protective levels for the resulting toxic gases? Can occupational and
ambient air standards be used?
When burned in air, most sulfur will be oxidized to sulfur dioxide (SO2).
Guidance and standards for SO2 have existed for many years, and exposures to
low levels of SO2 are common and generally well understood. SO2 is emitted
during combustion of fossil fuels that contain sulfur (e.g. by coal and oil power
plants, steel mills, refineries, smelters). Low levels of SO2 can constrict air
passages in the lungs and cause asthma attacks. At higher levels, SO2 affects
breathing, aggravates existing respiratory and cardiovascular diseases, especially
for asthmatics, individuals with bronchitis or emphysema, children and the
elderly. Still higher concentrations can result in skin and eye irritation, and even
death.
Table 1 shows several potentially applicable standards or benchmarks for SO2
exposures. The USA has three health and welfare based standards that are part
of the National Ambient Air Quality Standards: an annual arithmetic mean of
0.03 ppm (80 ug/m3); a 24-hour level of 0.14 ppm (365 ug/m3); and a 3-hour
level of 0.50 ppm (1 300 ug/m3). The first two standards are primary (healthrelated) standards, while the 3-hour NAAQS is a secondary (welfare-related)
standard. The annual mean standard is not to be exceeded, while the shortterm standards are not to be exceeded more than once per year. Recently, an
intervention level standard has been proposed to deal with high short-term
SO2 levels. Using five-minute averages, the programme establishes a concern
level of 0.6 ppm and an endangerment level of 2 ppm (2 January 1997, US
Federal Register). These very short-term levels are established as protective of
asthmatics engaged in mild physical activity. Table 1 shows WHO guidance
levels. These are lower than US standards and guidelines.
It is important to realize that the SO2 dose and resulting health impacts of an
exposure depend on both concentration and exposure time. While
considerable variability exists, the ambient standards indicate that levels where
health effects may occur in sensitive populations are about 0.1 ppm for 24hour averages, and 0.1-1 ppm for 1-hour averages. One-hour concentrations of
10 ppm are highly irritative; concentrations of 100 ppm (the level immediately
dangerous to life and health, or IDLH) may cause a rapid death.
Note that occupational levels are higher than environmental levels and are
designed for healthy and possibly adapted workers, not for the general public.

18

ANNEXES

Table 1. Summary of SO2 standards and guidelines.

Type

Standard or guideline

Average

Concentration

Ambient

WHO guideline

24 hour

0,06 ppm

WHO guideline

1 hour

0,16 ppm

WHO guideline

10 min.

0,24 ppm

US NAAQS

Annual

0,03 ppm

US NAAQS

24 hour

0,14 ppm

US NAAQS

3 hour peak

0,50 ppm

US EPA intervention level

concern
US EPA intervention level
endangerment

5 min

0,60 ppm

5 min

2 ppm

Emergency

IDLH

30 min

100 ppm

Occupational

NIOSH/OSHA STEL

15 min

5 ppm

ACGIH/TLV -TWA

8 hour

2 ppm

Ambient

Question 2. What immediate steps should be taken to protect public

health? What would you recommend?
Some possible responses might include:
step up fire-fighting efforts (although in the case scenario the maximum
effort was already being expended);
implement means to communicate with residents (few had telephones,
and at late hour, messages on radio or television would be ineffective; the
township eventually resorted to knocking on every other door);
suggest that people stay indoors and close windows (however, many
people live in shanty towns and probably cannot seal their homes; also,
this strategy will not work if the plume stays overhead for an extended
time as gases will eventually enter the house);
plan an evacuation route and coordinate with medical, emergency, public
safety and other personnel;
notify medical personnel and begin establishing emergency clinics nearby,
but in a safe area;
notify emergency responders and begin assembling safety, respiratory and
personal protection equipment; notify police;
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TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

evacuate susceptible residents (e.g. children, asthmatics, pregnant women,

etc.);
evacuate all residents (few residents own cars, so buses would be required;
about 800 bus trips would be required for all 40 000 residents, so 50-100
buses would be needed to accomplish the evacuation within several hours;
halt traffic on major roads crossing the plumes.
Question 3. What information is needed to assess the situation and
confirm your decision?
Necessary information includes:
the direction of the wind and the plume from the fire;
the number of people downwind of the fire;
the exposures or concentration expected in populated areas, based on
monitoring or predictions (well-established means exist for monitoring
SO2, ranging from relatively sophisticated real-time instruments to simple
colorimetric Draeger tubes);
evaluation of the likelihood and significance of exposures and health
effects (SO2 is one of the best understood air pollutants and standards are
commonly available; even so, there is little experience with short but
extremely high exposure levels).

Case scenario, Part II

On early Saturday evening, residents of Macassar were told to stay indoors and to close doors and
windows. Due to high winds (8-12 m/s), fire-fighting efforts were ineffective and the fire intensity
increased. Macassar was directly downwind. Because the wind direction did not vary from about 20.00
to 01.00 in the morning, concentrations in even well sealed homes increased and exposures were
prolonged. Residents began to experience increasingly intense discomfort, eye and skin irritation,
breathing difficulty, gastrointestinal cramps and respiratory distress. Shortly after midnight, an
evacuation of the town was attempted in a chaotic operation. Between 3000 and 5000 residents were
moved to a shopping mall in Firgrove about 5 km distant. Most left after midnight. Despite this effort,
approximately nine deaths occurred, including two men (both asthmatics) driving in opposite directions
along a highway. In addition, between 1000 and 2000 people visited emergency respiratory clinics that
were set up soon afterwards near the affected community, and approximately 15 people were later
diagnosed with chronic asthma-like respiratory disease. The chemical company sponsored several
emergency actions, including setting up local clinics where some health services (e.g. spirometry)
were provided in the days and weeks after the fire.

Question 4. What information, if any, should be obtained from

evacuees?
Basic information (e.g. name and residence) is essential.
Information that might show the dose (e.g. time leaving the area, time
spent in the area, any actions taken, type of house, etc.) is important.

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Symptom data (e.g. check for burning eyes, burning throat, cough,
wheeze, shortness of breath, vomiting, anxiety, fainting, fear) is also
important.
Note that the distress of evacuees, the late hour of the night, poor
planning, limited resources and general ensuing chaos is likely to hamper
data collection efforts, and most information may best be collected in
community in the next few days.
Follow-up checks might investigate the persistence (one day, one week,
one month, etc.) of nose, throat, chest or stomach problems.
Question 5. What concerns might you have for the health of the
evacuees?
The mental health concerns might be considerable. These may include
problems stemming from fear of what may happen to their homes and
possessions left behind, fear for their own health and the health of family
members and friends, and the effects resulting from social, emotional and
possibly economic disruption of their lives due to evacuation. Issues such as
the conditions of their temporary accommodation should be explored,
including sanitation and privacy. Particular attention should be paid to the
children. The physical health concerns are more obvious, but should also be
discussed.
Question 6. How might company sponsorship of the clinics affect their
credibility and utilization?
Diagnosis and damages may be based on clinic records, and the company
has interests in limiting claims against it.
Oversight by government health officers is necessary to provide
independent assessment of impact.
For a variety of reasons (including poverty, little education, lack of
political power), Macassar is medically underserved and the health status
of residents appears substandard. Thus, health records of pre-existing
conditions are minimal.
A complex issue is case-finding. Essentially, residents were self-referred to
the clinic. Thus, most persons visiting the clinic experienced health
problems during or after the fire. While many visits were made to the
clinic, there was no baseline or reference level of health status in the
community. As a consequence, only the most severe cases of respiratory
dysfunction were attributed to the fire. Also, because spirometry lung
function tests could not be performed reliably with children, no childhood
diagnoses of fire-related impact were made.

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TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

Case scenario, Part III

In the days and months following the fire, a moderate amount of sampling and analysis was performed
to investigate impacts related to the fire. Many residents suffering symptoms made repeat visits to
local clinics. Symptom information was collected for about 1000 individuals, and spirometry was done
on several hundred. Additional analysis was focused on ecological impact (e.g. impact on vineyards
some 10-25 km distant).
Approximately one year later, the duration and extent of exposures on the nearby population were
estimated using dispersion modelling. Using the best available data, air concentrations were predicted
for each hour of the fire. Figure 2 depicts a Gaussian plume model imposed on a photo of the fire
taken on Sunday morning (winds had considerably decreased and much of the fire was out by this
time). The plume has Gaussian profiles, depicting the spread of pollutants in the crosswind and
vertical dimensions.
Some of the dispersion model results are displayed in Figure 3 using isopleths or lines of equal
concentrations (like contour maps). The maximum one hour concentration ranged from about 10 to
200 ppm, and much of the area was exposed to 100 ppm for one hour. Thus, levels appear to have
approached or exceeded the IDLH value. Firgrove (where Macassar evacuees were accommodated)
was in a relatively low concentration area. Note that the maximum hourly concentrations are not
necessarily coincident in time, i.e. one cannot tell from the map what hour the exposure occurred. The
second highest hourly concentrations ranged from 10 to 40 ppm, and the 24-hour averages were from
1 to 15 ppm. These estimates indicate that concentrations in the Macassar community exceeded by
20-1000 times levels designed to be protective of health.

Figure 2. Depiction of the plume resulting from the fire. The plume width
and plume height follow Gaussian curves which are adjusted in practice (but
not in the figure) to match characteristics of the fires plume. Such models
allow concentrations to be estimated at many locations.

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ANNEXES

Figure 3. Isopleths showing the maximum 1 hour SO2 concentrations in

ppm in the Macassar area. The modelled area is 6 x 6 km, with the sulfur
fire located in the south-east corner and designated F. The complex pattern
results from wind shifts over the fire; most of the time, winds blew to the
west-north-west.

Question 7. What is air quality dispersion modelling? What information

is required?
Air quality dispersion models are mathematical tools used to predict air
concentrations and other impacts resulting from pollution sources. Such
models have a long history and broad use. They are suitable for predicting
ambient air quality concentrations, surface depositions and other results
from various types of emission sources over a range of distance scales (50
m to 100 km or more) and many time scales (short-term to annual
average). Many models can be run on a personal computer or laptop, and
many are based on a Gaussian plume formulation, as shown in Figure 2.

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TEACHERS GUIDE ON BASIC ENVIRONMENTAL HEALTH

The basic inputs to dispersion models include source information (e.g.

emission rate, temperature), surface meteorology (e.g. wind direction, wind
speed), upper air data and site information.
Question 8. How can a modelling analysis be used?
In this case, the model is run after the event to estimate concentration of
the substance in the air and the numbers of people affected.
The modelling can help identify individuals who were highly exposed for
further follow-up.
Modeling results can be used to help design a case-control study, where
health outcomes of exposed individuals are compared to those of
unexposed individuals. Model predictions would be used to determine
concentrations. Clearly, monitoring would be preferable, given the
uncertainties in modelling (see below), but this is the best that can be
accomplished for the AECI fire. Note the difference between case-finding
using the suggested case-control approach, and that accomplished at
Macassar where self-referred visits to the clinic were used.
There are several very user-friendly models like ALOHA or CAMEO
which can be used in an emergency and are designed for first-responders.
This would have been very helpful at Macassar to show zones which
should be evacuated. Fire-fighters and others may be trained to use these
models.
Question 9. What are some of the uncertainties in dispersion modelling
and the exposure assessment? What data would be useful?
Many exposure assessments have been performed, and many knowledge gaps
and questions can be anticipated, as follows.
The identification and quantification of the emission rates in a fire are
poorly quantified. Still, errors are unlikely to exceed 50%.
The meteorology may be complex and include large wind shifts. The use
of valid onsite short-term meteorological data to support air quality impact
analyses is necessary. It is best to have local data. Most of the data used
came from Cape Town airport, about 20 km distant. Substantial wind
shifts in mountainous and coastal areas are expected.
There were limited demographic, activity and health data on the affected
community (e.g. population density, housing characteristics like air
exchange rate, and activity patterns like time outdoors). Staying indoors
and keeping windows closed during the fire probably decreased exposures
by 25-75% due to limited air exchange rates.
There was very little monitoring during the fire. Two SO2 monitoring
stations existed at Bothasig and Table View, 33 and 38 km north-west of
the fire site and near oil refineries (see Figure 1). These instruments went
off-scale for several minutes when the SO2 plume reached them;
Bothasig at 2.5 ppm and Table View at 1.4 ppm. These concentrations
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ANNEXES

were reasonably matched by the model predictions, helping to confirm

model assumptions. Onsite monitoring might have been possible.
There are data gaps in our knowledge about adverse health effects from
specific hazardous substances. Sometimes, indirect exposure pathways
may present significant risks from chemical emissions, although inhalation
is likely to be the primary concern for the fires episodic SO2 release. More
significant here, however, is the lack of knowledge regarding brief, but
very high exposures to SO2.

Selected references
Documentation of the threshold limit value, 4th ed. Cincinnati, OH, American
Conference of Governmental Industrial Hygienists, 1980, pp. 377-378.
Batterman S. An Evaluation of SO2 concentrations resulting from the AECI Fire.
Report to the Legal Resources Centre, Cape Town, South Africa, 26 Jan. 1997.
Industrial Source Complex Dispersion Model, version 93109.
Environmental Protection Agency Research Triangle Park, NC, 1993.

US

Nappo C J et al. l982. The workshop on the representativeness of

meteorological observations, June l98l. Bull. Amer. Meteor. Soc. 1982, 63(7):761764.
Newhouse MT, Dolovich M, Obminski G, Wolff RK. Effect of TLV levels of
S02 and H2504 on bronchial clearance in exercising man. Arch. Environ. Health
1978, 33:24-32.
On-Site meteorological program guidance for regulatory modeling applications. US
Environmental Protection Agency, Research Triangle Park, NC, June 1987,
revised 1996.
White N. A survey of the health effects on helderbug community of smoke exposure from a
sulfur fire. Cape Town, University of Cape Town, 1996.

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