Impact case study database

Horwell’s research, to build an evidence base on the respiratory health hazards of volcanic emissions and effective methods of community protection, has resulted in incorporation of methodological protocols into country-level emergency management plans, co-development of informational products with communities and agencies, and their uptake and use during volcanic crises. This has resulted in raised awareness of effective actions in communities and changes in policy and practice related to mask distribution by agencies.

When a volcano erupts, agencies (usually GOs and NGOs with public health, civil protection, disaster management and humanitarian remits) will often distribute facemasks to reduce individual exposures to volcanic emissions, hence reducing the risk of harm from ash inhalation. Until recently, distributed facemasks have usually been those that have already been stockpiled for public health emergencies (e.g., surgical masks stored for influenza pandemics). Until the HIVE project, there was little-to-no evidence of the effectiveness of these masks in community settings for volcanic crises.

The Pan American Health Organization (PAHO) which is the World Health Organization’s (WHO) Regional Office for the Americas, has rewritten its guidelines on the health impacts of volcanic eruptions. Within those guidelines, information related to respiratory protection is based on the evidence provided by the HIVE research [E1]. These guidelines replace the current information available across the WHO, globally. The HIVE findings and impact were also summarised in a special supplement of PAHO’s Disasters Newsletter (October 2020), which reaches approximately 27,000 experts worldwide [E1], enabling awareness raising at a local level and, hence, faster implementation of the guidance during volcanic emergencies. A new IVHHN/HIVE standardised epidemiological protocol, for use in eruption crises, was also incorporated as part of PAHO’s Regional Response Team assessment tools. Dr Ciro Ugarte, Director of Health Emergencies at PAHO, has said: “The contribution of the HIVE project has been instrumental in building and sharing scientific evidence on respiratory protection from volcanic ash within the Americas. I would like to specially recognise Durham University for this essential collaboration towards a more resilient health sector in the Americas.” [E1]

In late 2017, the Mt Agung, Bali volcanic crisis triggered a critical shift in the approach to community protection in volcanic emergencies in low-to-middle income countries (LMICs). The fundamental difference between the preparedness for the Agung eruption, and that of previous volcanic crises in LMICs, came from a combination of changes in humanitarian practice, such as the advent of crowdfunding platforms, greater coordination of grassroots response, and a sudden move away from the precautionary principle (any intervention is better than no intervention) towards the principles of effectiveness (only providing proven interventions) and social justice (equality in public health provision). This ethical decision-making was based on the results of the HIVE project [R3-5], which showed that industry-certified (N95) masks were the most effective at protecting against ash inhalation [E2]. This resulted in the donation, stockpiling and distribution of 75,000 N95 masks in Bali by a consortium of NGOs known as Mt Agung Relief (led by Kopernik), a situation which has not previously been observed in a volcanic crisis in a LMIC (see [E1] for case study). Mt Agung Relief also produced a series of public informational products on ash protection based on the findings of the HIVE project [E2-3]. Horwell also shared the findings of the HIVE project through social media and engaged in discussions with communities in Bali through local Facebook groups such as Community Ubud, resulting in evidence-based community-level decision making [E3].

The results of the HIVE research [R3-5] have subsequently been incorporated into new public information products (printable and audio-visual), downloadable from the IVHHN website. They were co-developed with Indonesian NGOs, GOs and community representatives and are now available in English, Spanish, Indonesian, Filipino, Japanese and Turkish. The English and Spanish printable products (booklet, poster and leaflet) are endorsed by PAHO/WHO and carry their logos [E1]. These products provide information on how to protect from inhaling ash (2,443 video views 09/20) and how to fit a facemask (9,946 video views 09/20). Another video documents people’s experiences of protection during the 2010 Merapi (Indonesia eruption), to help people prepare for future eruption crises (9,618 video views 09/20). During the 2018 ash eruptions of Kīlauea volcano, Hawaii, a major PPE manufacturer donated over 100,000 N95 particulate respirators, in collaboration with local NGOs and GOs, a decision informed by the HIVE evidence [E4]. Local guidance was also developed by the Hawaii Department of Health (HDOH), based on the IVHHN products [E4]. Additionally, several NGOs in Indonesia have used the information to make their own products, for example, the Yakkum Emergency Unit has produced a series of posters [E5]. The Indonesian Red Cross (PMI) and Direct Relief (a US based humanitarian relief organization) have said that they will be printing and distributing the products in future eruption crises [E6; E7].

In January 2019, the HIVE project team returned to Indonesia to conduct four train-the-trainer workshops, on how to fit a facemask, for more than 70 representatives of local agencies and health centres, with the International Society for Respiratory Protection and the Indonesian Red Cross. Those representatives are now engaged in further training and, so far, at least 800 people have received this training [E6].

In Hawaii, the research finding [R6] that communities were coping with vog (gas) exposure in different ways from the official advice, and that the advice was viewed by some as inappropriate given their lifestyles, triggered a complete rewrite of that advice by the HDOH, US Geological Survey (USGS) and IVHHN (Horwell) [E4]. The research also showed how existing advice offered by different agencies varied on different websites. Through workshops held as part of the research, a new Interagency (GO) Partnership was formed (HDOH, Civil Defense, USGS, US National Park Service, County of Hawaii etc.) and an agreement was made that all future advice on vog protection would be consistent across the different agencies. The new guidelines have been published as a booklet, rack brochure and poster, and are available online on a new, comprehensive ‘web dashboard’ which Horwell co-designed with the interagency partnership. The Vog Dashboard ( https://vog.ivhhn.org/), is hosted by IVHHN so that no particular Hawaii/ US agency appears to lead the Partnership and all vog information and data can be accessed from one portal. The guidelines were written to be more reflective of Hawaiian lifestyles and to incorporate the communities’ strategies for coping, where these were evidence based. The agencies then removed their old advice from their own websites so that there was a single point of information [E8]. In May 2018, an unprecedented volcanic crisis emerged as the Kīlauea eruption changed location and style, resulting in multiple volcanic hazards and impacts within the community. The Vog Dashboard became a key source of official information, receiving approximately 50,000 visits per week during this crisis and was also highly recommended by various international media outlets [E9]. Fenix Grange, HDOH, said: “We are indebted to Dr. Horwell and IVHHN for the extraordinary, accessible technical resources and the expertise provided. Their contributions to the massive, multi-disciplinary response to the volcanic eruption crisis of 2018 (and prior events) were very important to the mission of HDOH to protect the people of Hawaii” [E4].

The ash analysis protocols, adopted by IVHHN, have been incorporated into New Zealand governmental policy to be enacted in any future eruptions [E10]. This coordinated framework for public health response to eruptions involves governmental ministries, the national geological survey (GNS Science), Regional Councils, the Met Service and universities. When an eruption occurs, the framework of responses will be enacted and ash collection and characterisation, in accordance with the IVHHN protocols, is part of that crisis management plan. Therefore, official guidelines and practice have been established which purposefully incorporate Horwell’s protocols. Horwell was invited to New Zealand, in Nov. 2013, to present her research to the governmental ministries and at a forum of regional public health representatives, which kicked off the process of writing and establishing the framework.

In 2017, key organisers of the framework (at GNS Science and Massey University) advised on crisis response for an eruption in Vanuatu. They enacted the IVHHN protocol, as part of that response [E10]. Parts of the IVHHN protocol have also been applied in other volcanic crises by local agencies around the world. “Claire’s work has led to improved capacity for rapid eruption response in both NZ and Vanuatu, including the activities of Civil Defence and Emergency Management Groups throughout the North Island.” Graham Leonard, GNS [E10].

To conclude, Horwell’s research on how to protect communities from exposure to volcanic emissions has influenced policy and practice in numerous health-facing organisations, around the globe, resulting in better preparedness, improved public health advice and protection, and enhanced understanding of the hazards of volcanic ash.