A One Health Approach to Harmful Algal Bloom Education and Outreach

Clark County Public Health (CCPH) is in Vancouver, Washington along the Columbia River in the Southwest Washington Columbia River Basin. Clark County is a unique mixture of urban and rural areas and is additionally influenced by Portland, Oregon located less than a 10-minute drive from downtown Vancouver. U.S. Census data published in 2020 estimates there are approximately 500,000 residents in Clark County which includes 110,000 dogs according to the non-profit Canines for Clean Water. U.S. Census Bureau data estimated that 90.0% of the population identified as not Hispanic or Latino and 10.0% identified as Hispanic or Latino. Majority of Clark County residents 85.4% speak only English and 14.6% (65,933 individuals) speak another language. Of those that speak a language other than English, Spanish (45.6%) and Russian (21.7%) are the most commonly spoken in Clark County.

In 2007, CCPH began testing lakes with a reported harmful algal bloom (HAB) for toxins as a part of a statewide program. Since then, 2018, 2019 and 2020 have been the most notable for reported HABs with 2020 resulting in a total of 97 lake samples collected across four different lakes, two of those lakes were under advisory for 35 consecutive weeks for elevated toxin levels. Since 2009, CCPH has received three reports of suspected dog deaths attributed to HAB exposure at different lakes in the county, the most recent in 2020.

In 2019, CCPH adopted a One Health approach to engage multisectoral agencies and stakeholders to prevent illnesses and potential pet deaths associated with HAB exposure. Through collaboration with local partners, we were able to connect and promote programs to our groups of interest including veterinary clinics, pet owners, and lake users. Outreach was aimed to not only educate lake users and pet owners to prevent illness while recreating outdoors but to also provide specific practices for how lake users can improve water quality.  Project objectives were to:

-          Establish routine means of communication to deliver timely water quality information to community and stakeholders.

-        Identify and provide outreach materials specifically for pet owners to protect dogs who make-up most deaths attributed to HAB exposure. 

-        Integrate messaging and opportunities on how to improve water quality of lakes and rivers with advisory communication encouraging safe recreation.

To accomplish project objectives, known stakeholders were contacted such as rowing/sailing clubs, personal watercraft rental companies, lakeshore HOAs, local/state agencies, and vet clinics to obtain a point of contact to send updates with lake advisory information as an email newsletter. In conjunction with improved outreach to stakeholders, CCPH created year-round HAB educational signs at all lakes that had toxic blooms across multiple years that were in English, Spanish, and Russian.

Multiple opportunities were identified through the creation of the updated signs and newsletter to integrate swim beach advisory information with other aligning programs including clean water, green businesses/homes, safe swimming, and zoonotic disease prevention. In 2021 the second year of the newsletter, topics were expanded from current advisories to include articles featuring different programs week to week. Several topics featured over the 14-weeks included a free online natural garden tour, eco-friendly car maintenance tips, rabies/tick prevention for people and pets while outdoors or promoting events like local lake management projects holding public comment. Community was engaged to join our newsletter through our social media posts on our Facebook and Twitter that included links for our followers to sign-up to receive the weekly emails.

Project objectives were met, success was measured using analytics of engagement with the newsletter and evaluation results of subscribers throughout the first two years of the practice. The first year, vet clinics participated in a phone interview to gauge satisfaction with the newsletter and determine gaps in knowledge of staff and clients regarding HABs. Survey results were used to inform changes made to format and frequency of the newsletter along with creating outreach materials specifically for pet owners. A tri-fold brochure was created based on their feedback that is being distributed to vet clinics along with other local partners. The second year, all subscribers were asked to complete an online survey at the end of the season to provide input on topics they wanted to see the following year. Between the first and second year, when newsletter content was expanded to include One Health messaging and promoted on social media, the number of subscribers increased including the open rate and click-rate. Subscriber's survey results also showed majority of respondents were interested in expanded topics promoting a One Health approach.

Specific factors that led to the success of this project was the engagement of local stakeholders and the ability to work with undergraduate environmental health interns apart of the National Public Health Internship Program (NEPHIP). NEPHIP through the National Environmental Health Association (NEHA) allowed our department to work with qualified interns eager to gain experience and contribute to our mission. Objectives were completed by three undergraduate interns across three summers each with unique working styles and interests that heavily influenced and helped this project succeed. Additionally, stakeholder engagement helped make the newsletter successful, partners were eager to share program activities and information. For example, we were able to promote a webinar for farmers hosted by the Washington State University Extension focused on reducing watershed impact, or the Scoop it. Bag it. Trash it. Everywhere” pet waste reduction campaign that offers free signs and handouts to remind the community to clean-up pet waste.

Positive feedback and increased audience show community support for continued use of email newsletters to keep public updated as a valuable resource when communicating lake advisories and education to protect water quality. Outreach material created as a trifold for this campaign was focused on protecting the health of pets from the risk of serious illness and death associated with exposure HABs. While the impact on the public is not direct, the benefit of avoiding HAB exposure and knowledge for how our community can prevent HABs and improve water quality is a clear benefit to the overall health of our community and shared environment.

https://clark.wa.gov/public-health

Harmful algal blooms (HABs) have become a growing public health concern both nationally and locally due to increased reports. According to the Centers for Disease Control (CDC), 14 states voluntarily reported 242 HAB events, 63 human cases of illness, 367 animal cases of illness and 207 animal deaths in 2019. Locally, HABs have become a growing issue in our community since Clark County began weekly monitoring of reported HABs in 2007 as a part of Washington State Department of Ecology's Freshwater Cyanobacteria Monitoring Program. Between 2009 and 2014, CCPH collected and sent 24 lake water samples to be analyzed for cyanotoxins in response to reported HAB events, with 2 lake samples during that time had elevated cyanotoxins that resulted in a lake advisory or closure. Between 2015 and 2020, over 150 samples were collected in response to reports of HABs with 42 (27%) of samples having cyanotoxins high enough to cause concern for acute health effects in people and animals.

In 2016, CDC officially launched the One Health Harmful Algal Bloom Systems (OHHABS) which is a voluntary reporting surveillance system that collects information on human and animal illnesses caused by HABs. This system was modeled after the National Outbreak Reporting System (NORS) launched by the CDC in 2009 as a web-based platform into which health departments enter outbreak information. CCPH began reporting to OHHABS in 2020 in response to a suspected dog death attributed to recreating at a lake with a confirmed HAB. In addition to the reporting system, resources and communication materials were created by the CDC for veterinarians, medical professionals, and the pubic to provide messaging on how to report and protect themselves from HABs.

The One Health approach is a principal developed by the CDC which encourages collaboration across organizations and agencies with the goal of achieving optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. Cross collaboration between Public Health and Primary Care is a One Health concept that is growing in both interest and importance from both sectors as we realize the overlap between these two industries and the potential for improved public health that could result from close partnerships.

The exact cause for the increase in HABs locally cannot be pinpointed to a specific source however, factors that have led to the deterioration of our local lakes that make toxic blooms more likely could be attributed to the increase in population. According to U.S. Census data, Clark County has seen a dramatic increase in the population, between 2010 and 2020 the population of increased from 425,363 to 503,311 for a 18.3% growth rate, the second highest in Washington State for that period. In the last 30 years the population of Clark County has doubled. With more people comes more nutrients from fertilizer, pet poop, and car drips that all flow into our streams and lakes via our stormwater system. More people require more roads, driveways, parking lots, and other paved surfaces that easily allow pollutants around our homes and businesses to run-off directly into our stormwater. Finally, increased development has also resulted in a loss of trees and vegetation which reduces shade and warms water temperatures.   

Lake management efforts specifically to improve watershed health and decrease the incidence of toxic algal blooms have and are currently underway but, these do not replace the need for ongoing nutrient reduction and stormwater protection across our community. Prior to the increased awareness of HABs, many local agencies and organizations work centered around protecting and supporting clean water providing education and outreach. This educational work was in addition to local and state agencies that conduct active monitoring of streams and watersheds to identify and fund water quality improvement projects as mandated by state and federal requirements.

Previous communication strategies during a lake advisory consisted of press releases and social media posts to Facebook and Twitter when an advisory was issued or removed. Public Health webpage had current advisories listed, a brief description of monitoring activities, and information on how to report a water quality concern such as a sewage spill or HAB.  

Clark County Public Health began to work on improving communication across partners by establishing an email distribution list to provide direct advisory updates when they occur during our monitoring season. To provide timely water quality information we identified lake user groups such as rowing/sailing clubs, triathlon­­ training groups, kayak/SUP rental companies, and lakeshore HOAs as our main audience for our email newsletter. Additionally, local/state agencies (e.g., Fish & Wildlife, WA State Poison Control) were included so that they could have situational awareness of current water quality advisories that may result in calls from the public and provide easy contact information for our department. Vet clinics were also contacted as a group to receive advisory updates via email as they are a primary care provider for local pets.  

To reduce HAB related illness and death in the most heavily affected population, dog owners were identified as a target population for outreach to reduce HAB exposure. According to local non-profit Canines for Clean Water, it is estimated that there are 110,000 dogs living in Clark County. Using American Vet Statistics data estimating that every household that has a pet dog has approximately 1.6 dogs, we calculated there are approximately 68,750 households in Clark County that have pet dogs. Vet clinics were identified as group that could provide insight into what materials would be best for pet owners and a distribution point of resources and information. Contact information for 30 vet professionals representing approximately 40 clinics in our community were obtained to send advisory updates and contacts were surveyed to determine what materials would most beneficial in educating clients regarding HAB exposure. This outreach campaign identified a valuable and attainable extension of the One Health concept in establishing relationships with local veterinary clinics to protect the health of pets and lake users from understood environmental concerns.

Based on the feedback the vet clinics provided via survey done over the phone, we were able to print 4,000 brochures for pet owners intended to be distributed by vet clinics, clean water programs, and other agencies like animal control and parks departments with the intention to reach approximately 17% of dog owners through our initial outreach. When vet clinics were contacted to determine number of brochures they would need for their practice, they were also asked what materials they needed in Spanish when available by the CDC and any additional languages that would be useful for staff and clients to inform future document translation projects.

Using a One Health approach and building off materials and resources provided by the CDC and EPA regarding HABs, local agencies working to support protection of our environment and safe outdoor recreation were asked to share program activities that focused on how the community could protect themselves and our local waterways when communicating advisory information. The goal of including this messaging with the public and primary care providers was to increase engagement regarding protecting water quality and preventing illness influencing behavior change. Email newsletters were sent every Friday during the swim beach season that contained advisories for that week and at least one featured article from local partners. For example, a few of the topics and events promoted throughout the 14 weekly issues included rabies/tick prevention for humans and pets in partnership with Public Health Communicable Disease Program, drowning prevention tips from the CDC, information for MED-Project a statewide unwanted prescription medicine take back program, a virtual natural garden tour organized by Clark County Green Neighbors, Canines for Clean Water pet waste reduction program, and eco-friendly car maintenance habits in partnership with Clark County Clean Water.

The population in Clark County is primarily white/Caucasian however those that frequent local lakes are observed to also include other non-English speaking populations including Spanish and Russian speakers. It was identified that obtaining veterinary care for pets is not an option for all households due to barriers such as cost, access, and potential lack of awareness to the importance. Furthermore, email newsletters are currently only available in English with sign-up through our website. To further prevent toxin exposure at lakes that are prone to HAB events, 2-foot by 3-foot permanent educational signs were posted that include Russian and Spanish translations. Large infographics were included to convey clear messaging across multiple languages that informs lake users on how to recreate safely knowing potential risks. Signs included a QR code that when scanned took lake users to our website that had all current advisories listed and other educational information available in almost 70 different languages.

This practice was innovative in that advisory communication to lake user groups who are most effected by lake advisories were also sent information on how they can recreate safely and improve water quality. This outreach allowed for increased awareness with the hopes to influence behavior in groups vunerable to illness/injury and most motivated to protect their local lakes. During, the first two years of this practice the number of subscribers to the newsletter increased from 46 individuals and organizations to a total of 192, as of December 2021. Evidence gathered throughout the outreach campaign showed a high level of interest and engagement from stakeholders supporting a One Health approach when educating partners and the public about HABs.  

The goal of the practice was to increase awareness and outreach among the public and key partners about harmful algal blooms and recreating safely in our community to reduce illness and injury associated with recreating in our local waterways. Project Objectives:

-        Establish routine means of communication to deliver timely water quality information to community and stakeholders.

-        Identify and provide outreach materials specifically for pet owners to protect dogs who make-up most deaths attributed to HAB exposure. 

-        Integrate messaging and opportunities on how to improve water quality of lakes and rivers with advisory communication encouraging safe recreation.

The first phase of this effort began during our 2019 swim beach monitoring season when we reached-out to known lake user groups based on prior monitoring and communication with concerned citizens. We worked to establish routine means of communication to deliver timely water quality information via an email newsletter when advisories were issued or removed. The types of stakeholders that we engaged to receive the email newsletter were known lake user groups of waterbodies prone to harmful algal blooms. Known stakeholders contacted to establish regular communication included lakeshore HOAs, rowing/sailing clubs, kayak/SUP rental companies, and vet clinics. Additional agencies contacted were local park officials/lake managers that assist with advisory postings and other government/agency officals. For example, Fish & Wildlife, Poison Control, and state department of health were subscribed to the newsletter as they benefit from situational awareness of water quality advisories.

Initial attempt to contact known stakeholders based on previous HAB monitoring activities and cold calling resulted in 46 contacts subscribing to direct email advisory updates, 30 of which were vet clinics representing approximately 40 clinics in our area. Vet clinics were contacted as they were identified as a key stakeholder that could help increase reporting of suspected HAB illness and share materials to help prevent exposure in dogs and animals that are most vulnerable to illness/death from contact with HABs.

Starting in June 2020, we sent our first advisory update to our initial subscribers for a HAB advisory issued at a local lake. At the beginning, email newsletters were only sent when a press release was issued which occurred when an advisory was issued or removed. Contents of newsletter was copied from press release with links to the Public Health webpage where all current advisories were listed. If an advisory wasn't being upgraded or downgraded, no press release was issued, and no newsletter was sent. Additionally, email distribution lists were divided into user groups of the different lakes that were monitored. If a user group was located at a certain lake that did not have an advisory, they w­­ould not be alerted to an advisory at another lake in the county. Some groups were on multiple lists such as veterinarians and agency officials, this meant they could receive duplicative emails if there were multiple lakes with advisories at one time.

To gauge satisfaction with the newsletter, vet contacts that agreed to receive the newsletters, consented to a phone interview to discuss incidence of suspected HAB-related illness and materials vets would find most useful. Major insights included desire to receive regular updates on a routine schedule, instead of just advisory notifications. Also, several clinics expressed desire for a brochure to distribute to new pet owners with other materials commonly called new puppy packets”. Separate comments received from lake user groups during regular email communication also expressed desire to receive more frequent updates, links where they could find test results and further information regarding monitoring done.  

At the same time, we were conducting these interviews and receiving feedback on the first few issues of the newsletter, it was the worst year on record in Clark County for weeks of advisories due to elevated toxins detected across multiple lakes that had reported HABs. Monitoring of algal blooms is done in response to reports by­­­ partners but mostly, the public when out recreating. That same year, due to the COVID-19 pandemic, there was an increase in park use according to local parks department officials. The exact cause for the increased detection of algal blooms cannot be explained however, the effects resulted in amplified interest across agencies and the public to understand and prevent algal blooms at their favorite lakes. Additionally, the need to provide readily accessible and equitable notifications of water quality concerns to protect lake users was identified as a high priority to protect the public.

During the winter of 2020, project activities focused on improving website content to display a data dashboard and more information on HABs. Website content was adapted from readily available infographics from EPA HAB communication resources and information on the Seattle-King County Public Health website regarding causes and sources of HABs. Website content added was sent to local partners that supported clean water including local public works agencies that conduct stormwater monitoring and improvement projects, SW Washington Stormwater Partners that provide education and outreach, and Public Health Solid Waste Education & Outreach that manage Clark County Green Business and Green Neighbors that provides resources on how the community can protect their environment through everyday behaviors. Partners were asked to review content to find areas where their program information could be incorporated when discussing ways to protect our local lakes and their general input on what could be improved. Comments were captured via email and incorporated prior to going live to the public before the start of our 2021 monitoring season.  

Partners were also asked to identify program topics or events that could be promoted in the email newsletter, each agency/program was met with either via phone or virtual meeting to discuss the intent and scope of the newsletter and what activities from their programs could be promoted. Partners that contributed content to the newsletter included SW Washington Stormwater Partners, Clark County Clean Water, Clark County Green Neighbors, Clark County Green Business, Clark County Communicable Disease, Washington State University Extension, and other municipal Public Works agencies. Partners shared resources, program activities, and events to cross-reference and promote healthy recreation and improved stormwater to keep our lakes and rivers clean.

While focusing on broadening the audience and scope of the email newsletters, barriers that exist limiting access to internet, email, and the ability to check water quality information before you get to the water needed to be considered to protect most vulnerable populations. Lake side messaging regarding HABs and the risk when recreating was previously only posted at waterbodies that had a confirmed harmful algal bloom CCPH was monitoring, and advisory signs posted were only available in English. Additionally, the lag time between our department receiving the report from a concerned lake user, investigating, sampling, coordination with parks officials to post signs, and issuing a press release led to delays in getting the information visible at the waterbody and available to the public. Year-round educational signs were proposed for lakes that were prone to HAB events. Additional languages were identified as a concern that needed to be incorporated based on community and park agency input, most spoken language besides English is Spanish and Russian, were added to sign along with large icons depicting lake use recommendations to promote understanding across all languages.

By June 2021, the new translated educational signs were posted at waterbodies across the county that were prone to toxic algal blooms, the website had been updated to incorporate resources on what the community could do to promote clean water, and the first issue of the improved In the Splash” email newsletter was being sent every Friday morning. Over 14 weekly issues, subscriber count increased from 56 to 188 with 65% (123) subscribing through a sign-up link shared on Facebook, Twitter, and on our website. Towards the end of the 2021 monitoring season, subscribers were asked to complete an online survey to provide feedback on their satisfaction with the newsletter and future topics they would like to see.

Based on vet clinic input from the previous year, a trifold brochure was created in 2021 that contained information veterinarians interviewed specifically requested such as signs and symptoms of HAB exposure in animals, how to report suspected pet illness/death to Public Health, and the importance to seek immediate veterinary care if you suspect exposure. Brochures will be distributed primarily by vet clinics with other resources provided by the CDC. However, other partners supporting a One Health approach including clean water program partners during their outreach events, municipal animal control offices, and park agencies will also be distributing the brochure. The goal to reach 17% of Clark County households with pet dogs the first year.

Majority of practice activities were completed over a period of three summers (2019,2020, and 2021) by three separate undergraduate interns a part of National Environmental Public Health Internship Program (NEPHIP) as our program activities are seasonal during the height of outdoor and water recreation during the summer. Internship time and funding was provided through the National Environmental Health Association (NEHA) with intern work focusing in understanding need, collaborating, and developing this campaign. Program and managerial support for this program are provided through the Water Recreation Safety program within Clark County's Environmental Public Health department. This program is 100% cost recovery through environmental health fees obtained through permitted water recreation facility permit and plan review processes. Some county general funds are used in support of swim beach monitoring totaling ~$6k. Staff time to support intern in summer and continue program activities during winter months was calculated to take 4- 20 hours of their time every week, variation was most dependent upon whether there was water quality advisory necessitating additional time spent coordinating advisory notification with partners. Onetime costs included cost to print 4,000 8.5”x11” brochures on cardstock for approximately $200.00 and translated HAB advisory signs were a one-time cost of approximately $6,200 to order 40 of each of the different signs, 120 total. Other ongoing costs specific to this practice include subscription to an online email newsletter platform that cost $20.00 per month. Algal toxin laboratory testing that informs advisories is funded through the Washington State Department of Ecology Freshwater Algae Control Program. 

Success of the practice was measured in engagement with the email newsletter and survey results of target groups to identify improvements in the newsletter and outreach materials. The two deliverables evaluated as a part of this project were materials created specifically for vet clinics to increase outreach to pet owners locally and the email newsletter to lake users and stakeholders. Veterinarians and email newsletter recipients were surveyed throughout the first two years of the practice to ensure messaging met needs of community.

For newsletter campaigns, online digital marketing platform Constant Contact was used to create and send newsletters as platform allowed for easy contact management, ability to create user friendly and visually appealing campaigns, and ability to have people sign-up through a web link or a sign-up form embedded into a webpage. Within Constant Contact, insights and data was captured and downloaded into Microsoft Excel to compare success of the newsletter across the first two years.

For the first year of the newsletter during the 2020 summer monitoring season, 46 contacts had been identified and subscribed to the advisory updates based on the outreach done in 2019. Between March and August of 2020, 8 advisory updates were sent with an average open rate of 45.9% and an average click rate of the website link provided being 10.8%. Newsletters during this period only had information taken directly from issued press releases, only one website link was included that took readers to our webpage with current advisories.

During this same period, out of the 30 vet clinic contacts that subscribed, 15 consented to a phone interview in 2020 to discuss incidence of HAB exposure and educational materials that would be helpful for staff and clients. Interviews consisted of seven questions that served as a framework for an open-ended discussion with either the clinic manager or a veterinarian on staff. Questions consisted of asking about occurrence of suspected HAB toxin exposure, willingness to participate in a reporting system like CDC's OHHABS, and materials that could assist to help educate pet owners. Some key take ways from those interviewed were that only 3 clinics out of the 15 interviewed stated they saw any suspected case of HAB-related illness and none in recent memory, they characterized occurrence as rare”. Of the vet clinic contacts interviewed, 11 stated they would be willing to report suspected HAB-related illnesses and all 15 stated they would benefit most from a brochure that included information such as signs and symptoms, urgency to seek immediate vet care, and reminding the public that blooms can happen year-round. Several vet clinics also provided input on the email newsletter and requested for regular updates with advisories across the whole county listed instead of separate advisory updates each time a lake advisory was issued or removed. This resulted in multiple emails within a single day when blooms occurred across multiple lakes at once during the 2020 monitoring season.

By the second year, with the incorporation of stakeholder messaging to promote a One Health approach by educating the public on protecting our local environment and safe recreation, 54 contacts were subscribed to receive weekly updates during our monitoring season. These weekly updates included current advisories along with safe recreation and clean water messaging on a wide variety of topics. These articles were from different programs with links to their website for more information. In 2021, the audience of the newsletters was broadened to the general public and the newsletter was promoted on our Facebook page which resulted in over 123 individuals subscribing to our newsletter.  

To evaluate the success of changes to the newsletter content during the 2021 monitoring season, a Microsoft Forms online survey was advertised within the newsletter during the last 3 issues of the season. Questions were aimed to determine types of individuals that were reading the newsletter based on the increase in subscribers and what topics they wanted to see in future seasons. Survey link was shared with all 177 subscribers at the time with approximately 50% opening the email over the several weeks the survey link was included.

In all, 12 subscribers completed the short 2-minute survey, of those that responded when asked to describe their interest in the newsletter, 6 stated they are a regular lakes user”, 7 stated they were interested in improving water quality”, and 3 stated they were a homeowner near a lake”. No vet clinics or veterinarians subscribed to the newsletter completed the survey. Additionally, of those that completed the survey, 7 stated they were very satisfied” with the newsletter, 4 were somewhat satisfied”, and 1 said they were neutral”. No participants stated they were somewhat dissatisfied” or very dissatisfied”. When asked to rank their interest in a handful of topics previously included in the newsletter, all topics listed had a majority stating they were very interested”, with very few respondents rating a topic as not interested”, neutral”, or somewhat interested”. Overall, 90% were very interested” in HAB and E. coli advisory updates, 75% were very interested” in recommendations for safe recreation/swimming, 66% were very interested” in tips to reduce impact on stormwater, 66% were very interested” in real-time lab results, and 50% were very interested” in recommendations for pet and animal owners. Open comment box where respondents could say what additional topics should be included in the newsletter were, updates on efforts to coordinate with city governments and HOAs”, efforts County is making to expand recreation access…”, homeowner/private land management impacts on surrounding environmental areas”, and other comments wanting additional information on our regular monitoring activities.

Along with the positive feedback from the survey, analytics comparing 2020 engagement data with 2021 shows that as the number of subscribers increased from 56 to 188 by the end of the monitoring season, the average open rate also increased from 45.9% to 53.6% and the average click rate increased from 10.8% to 12.1%. This is above the industry average for government email campaigns calculated by Constant Contact of a 26.1% open rate and 1.42% click-rate. Out of the 14-weekly email campaigns, the top five newsletters during 2021 that achieved the highest open rate ranged from 56.1 to 64.7%, three of these were weeks when a water quality advisory was issued. The newsletter that had the highest open rate of 64.7% also had the highest click rate of 17.5% with most clicks, 31.6%, visiting our webpage and 21.1% were readers visiting the Clark County Green Neighbors online virtual natural garden tour. Newsletter data and survey results show that subscribers are engaged with the content and appreciate the combination of current advisory information with messaging that promotes a healthy environment.

With the newsletter being promoted on social media and website increasing the audience of the newsletter, engagement among vet clinics was unchanged between 2020 and 2021. Comparing email newsletters both sent on August 8^th, 2020 and 2021, the number of vet clinics that opened the newsletter only increased by 1 from 12 to 13, which is less than half of 30 clinic contacts that are subscribed. This stagnation identifies the need for continued engagement of veterinarians to determine best route to disseminate information to staff and clients as an ongoing objective as HAB events persist at our local lakes. Vet clinics were sent a Microsoft Forms survey to order the tri-fold brochure and other HAB educational materials to reestablish a email point of contact and determine what additonal resources and translated languages would be most beneficial to staff and clients.

The success of this practice was driven by the support and collaboration of partners. Veterinarian clinics were invested in providing input on outreach materials that would educate pet owners on how to avoid HABs while out recreating preventing exposure. Clean water partners were invested in the practice as a way to promote programs and events that can be shared to residents to influence behavior change. The success of the outreach materials created out of this practice were driven by the collaboration of partners and their aid in distribution to help educate community lake users and pet owners on how to prevent and protect themselves from HABs. Participation and engagement from stakeholders continue to prove the investment in the sustainability of this practice.  

One lesson learned in relation to this practice was the necessity to continue and expand social media messaging to reach a larger audience. In 2020, the newsletter was not advertised to the general public with interested groups being asked to participate directly. The number of subscribed organizations and businesses during the first year increased from 46 to 56. During that same period, Facebook posts regarding advisory issued for local lakes were reaching thousands of people. For example, a HAB advisory issued and posted to Facebook July 27, 2020 reached 28,930 people as the original advisory post was shared over 290 times.

In 2021, links to sign-up for the email newsletter were embedded into several Facebook posts throughout the monitoring season. Over 14 weekly issues, subscriber amount increased from 56 to 188 with 65% (123) subscribing through a sign-up link shared in social media posts regarding our swim beach monitoring program and links on our website.

Another lesson learned is that the public is most engaged with content and information provided when a water quality advisory is being issued. Leading up to and throughout our swim beach monitoring season, one to two posts per week relate to our swim beach monitoring program or safe recreation. For example, topics like safe swimming, lifejacket use, advisory updates, at home pool safety, etc. When comparing 2021 analytics provided by Facebook, an August 4^th Facebook post regarding a lake advisory being issued reached 17,979 people and was shared 107 times, compared to an educational post during that same period on July 2^nd that reached 11,589 people and shared 50 times that contained general information on identifying HABs. One of the lowest performing Facebook posts during that same period was a June 16^th post advertising the latest issue of the email newsletter that reached only a few hundred people and was only shared 3 times. This was true for our email newsletter as well where weeks where an advisory was issued outperformed weeks where there were no advisory updates. The attention and engagement during an advisory event provide opportunities to expand the reach of these cross-sectional programs and topics that increase understanding of negative health effects attributed to water quality and behavior change the community can implement to protect their local lakes. Continued success of the practice necessitates resources to maintain Facebook and other social media accounts so that they provide accurate, trusted, and equitable content that engages the community.

Internship support through the NEPHIP program significantly offset costs to complete practice objectives. Undergraduate environmental health interns worked 40 hours/week for 10 weeks between June and August focusing their work on CCPH's Swim Beach Program with their wages paid by NEHA. In 2019, internship duties included lake sampling, building email contact list creation for the future newsletter, and other special projects. CCPH staff time overseeing intern and total spent on the swim beach monitoring program accounted for 150 hours or 7% of the EHSs total work time in 2019.  Due to COVID-19, internships were remote in 2020 and 2021 necessitating CCPH staff conduct lake sampling activities and fieldwork previously done by internship staff. EHSs hours that were spent on the swim beach monitoring program increased to over 400 hours and more than 20% of their total time. Even with internships staying remote, internship staff were still able to complete the practice objectives including drafting email newsletter content, administrating surveys of subscribers, drafting pet owner HAB outreach brochure with vet input, cross partner collaboration through emails and virtual meetings, etc. NEPHIP is a competitive process that requires health departments apply annually to be selected and matched with an undergraduate or graduate intern. To offset costs and ensure program development will require continued search for funding streams to attract students or citizen scientist to work with CCPH on lake monitoring to inform advisories.

As the state increases funding for Foundational Public Health Services (FPHS), HABs were included in the scope of work for this funding to be applied. Clark County has spent significant time supporting this work prior to FPHS funding and hopes to apply this and new funding to HAB related monitoring, outreach and education to the public and other government agencies that are interested in improving water quality. Additionally, this funding will be used to support procedure/protocol development in solidifying this work locally. Clark County Public Health believes strongly in supporting other counties that don't have the sustainable funding stream to support similar initiatives and hopes to share processes and experience with those interested counties.