Determining Recommendations and Developing a Public Health Action Plan

This section describes criteria to determine recommendations for follow-up actions to protect public health.

After reaching conclusions about a site, you should consider recommending that actions be taken to protect public health. These recommendations should emphasize prevention of releases and exposure, as well as precautions to protect public health. Because ATSDR is an advisory agency and not a regulatory agency, your recommendations might identify actions that other entities (e.g., site owners, state health or environmental agencies) should take. ATSDR uses specific language about reducing and eliminating exposures when making recommendations, but always does so without making suggestions related to risk management actions and decisions. For example, ATSDR will make statements about a particular desired goal (e.g., reduce exposures to arsenic in soil), but does not specify how or what actions a responsible entity needs to take to meet that goal. In other words, the way to achieve ATSDR’s stated goal is left up to the party who will take the action. Work with your team members to determine the most appropriate recommendations for your site.

In general, your recommendations should identify the following:

  • Practical ways to stop, reduce, or prevent exposure, if applicable
  • Activities to further characterize the site and possible exposure
  • Service- or research-oriented health activities (e.g., health education, health studies, health surveillance, contaminant-specific research) [See this Uranium Case Study Example in ATSDR’s Community Engagement Playbook where the community acts as a partner in reducing exposures.]

Depending on the site-specific situation, your recommendations should consider short-term and long-term public health needs. For example, short-term recommendations might include supplying bottled water or conducting an emergency removal action. Long-term public health protection needs might include institutional controls for restricting site access, deed restrictions on land use, and continuous environmental monitoring for specified periods.

Developing Recommendations for Public Health Actions

Make recommendations that

  1. Specify who will perform an action (if possible)
  2. Are measurable to evaluate effectiveness
  3. Indicate ongoing tasks
  4. Identify time-related actions (to help with prioritizing)

In addition to stating recommendations, you will include a Public Health Action Plan (PHAP) in all PHAs. This is not needed if the site is categorized as no exposure, no harm expected (Category 5). You might also include a PHAP in a health consultation, depending upon site conditions and community interest. The PHAP outlines the following:

  • Actions or activities that have been taken to protect public health
  • Activities that are currently underway
  • Activities that will be conducted in the future

Actions described in the PHAP will vary by site. The plan needs to clearly describe the implementation and timing of the recommended public health action(s).

If an urgent public health hazard exists, take immediate action by notifying your supervisor before completing the PHA process. ATSDR will notify appropriate state, tribal, and local entities and work with them and others to protect the public. If the health assessor determines that one pathway, contaminant, or issue is an urgent hazard, focus the evaluation on this issue to expedite the evaluation process. This often occurs in the form of a technical assist document or a letter health consultation.

Recommendations that ATSDR might make depend on the site’s conclusion category and correspond directly to the specific conclusions drawn about a site (see examples of suggested recommendations in the Summary of Conclusion Categories table below).

Summary of Conclusion Categories with Suggested Recommendations

Who is Involved in the PHA Process
Overall Health Hazard Conclusion
Conclusion Category
Type of Example Recommendations
Health Hazard 1: Short-term exposure, acute or intermediate hazard Measures to immediately stop or reduce exposures, if appropriate. Describe actions already taken and planned.
Health Hazard 2: Long-term exposure, chronic hazard Measures to reduce or prevent chronic exposures. Describe actions already taken and planned.
Uncertain Health Hazard 3: Lack of data Measures to fill critical data gaps to enable a public health determination. Describe needed actions.*
No Health Hazard 4: Exposure, no harm expected No action might be necessary. But if site issues and community concerns are identified, describe needed actions to address those.*
No Health Hazard 5: No exposure, no harm expected Likely no action required.*

*Conclusion categories 3, 4, and 5 can relate to acute, intermediate, and chronic durations.

Recommendations to Prevent or Reduce Exposure

Health assessors need to recommend suggested actions (see Factors to Consider table [PDF – 253 KB]) that could accomplish the prevention and reduction of exposures. ATSDR would recommend these types of actions when the PHA process identifies current exposures to contaminant levels associated with harmful health effects. Suggested actions you might recommend that other entities (e.g., site owners, state health or environmental agencies) should take to prevent or reduce exposures could include the following:

  • Removing physical hazards (e.g., unsafe structures, unexploded ordnance)
  • Informing affected populations of contamination or exposure
  • Establishing institutional controls on land use
  • Restricting public use of or access to a site
  • Restricting use of drinking water supplies or providing alternate water supplies
  • Establishing measures to restrict contaminant migration
  • Remediating contaminant sources
  • Establishing safety plans and monitoring during removal actions and remediation
  • Evacuating or temporarily relocating populations

Recommendations When Data Are Missing

In cases where data critical to your public health conclusion are missing, include brief explicit recommendations that outline the information required and why it is critical. Working with other stakeholders, identify the data needed, where it should be collected, who should collect it, and who should receive and evaluate the data. ATSDR may recommend that appropriate entities take actions that could include the following:

  • Conducting additional or continued environmental monitoring.
  • Conducting private well or public water system surveys.
  • Conducting surface water use surveys.
  • Conducting plant or animal consumption surveys.
  • Conducting land use surveys.
  • Further characterizing demographics of potentially affected populations.
  • Characterizing human activities on or near the site.
  • Characterizing contaminant sources.
  • Characterizing explosion potential.
  • Characterizing hydrogeology.
  • Characterizing radionuclide activity.

If you can obtain the data in a timely manner, start the collection process as described and complete your document (see Documenting Insufficient Data Example) using the information you have. Update the document or add an addendum when critical data become available. You might also release a new document (e.g., HC) that incorporates your new understanding of the site.

Documenting Insufficient Data Example

Scenario: A site does not have groundwater sampling data or the data are of insufficient quality or quantity. In your document, you state the following:

ATSDR has evaluated regional groundwater flow patterns (site-specific potentiometric maps are not available). ATSDR determined that on-site trichloroethylene-contaminated groundwater from the Puget Dry Cleaners might flow toward off-site private drinking water wells. The discovery of groundwater contamination at the site is recent and therefore, no groundwater sampling data are available to date. As such, ATSDR cannot conclude whether trichloroethylene from the site could harm people’s health currently. ATSDR is working with the State of Maricopa to gather the needed information.

Recommendations for Additional Follow-up Activities

You can consider various follow-up activities depending on the degree of exposure or hazard identified, coupled with the overall level of community health concern and other factors such as the community’s stress level. Base your recommendations on your site-specific public health conclusions. Include activities aimed at further evaluating the health status of the site community and educating the community and other stakeholders about potential exposure and health effects (physical and psychological) related to the site.

Recommendations could include

  • Conducting biological testing for exposure or changes in body function,
  • Conducting health education,
  • Performing health surveillance,
  • Conducting a health study, and
  • Conducting contaminant-specific research.

This table [PDF – 253 KB] describes various follow-up activities and highlights factors to consider in determining their appropriateness. While there is no formula for determining which, if any, of these activities you should recommend, the questions in the table can help guide site-specific decisions. It is also important to reach out to SMEs (e.g., epidemiologists) before finalizing any recommendations.

Consider your options in consultation with your team, appropriate technical experts, and the agency or other stakeholders responsible for implementing the activity (e.g., health education specialists, local health departments, area physicians). For example, confer with an epidemiologist before recommending a health study to ensure the feasibility and appropriateness of such a study. Also, if the PHA process reveals a need to educate local physicians, seek out health educators who ultimately might provide the needed education. Also consider recommending engagement activities where the community can act as a partner to prevent and reduce exposures.

Factors to Consider When Developing Recommendations

When developing recommendations, focus on suggesting measures to prevent or eliminate exposures to harmful levels of hazardous substances or obtain more information for improving your evaluation of possible public health hazards. You are not required to determine what specific action is needed or exactly how to achieve it to reach your objective, but you should work closely with other entities responsible for implementing the recommendations (e.g., other federal, state, or local agencies; tribes; the community; private parties). Remember that ATSDR suggests ways that these entities can reduce and eliminate exposures, but always does so without making suggestions related to risk management actions and decisions.

Remember: Maintain open lines of communication with all stakeholders regarding recommended public health actions during the development of the document and after its release. This will help ensure needed actions are taken, and the agency’s ultimate goal is achieved — that is, protecting public health.

As you work through possible recommendations, keep the following questions in mind:

  • What feasible, reasonable action is needed to prevent or reduce exposure?
  • Who will implement the action? Have you discussed the reasoning behind the action with responsible stakeholders to obtain their inputs?
  • When will the action begin? Is the time frame reasonable?
  • What are the desired outcomes?
  • What population will the action affect?
  • What is the effect or health consequence of not implementing the action?
  • When will the agency reevaluate the site or actions?

Use this type of worksheet to help formulate recommendations. The worksheet is completed to illustrate considerations using an example scenario for which biomonitoring has been recommended at a site with lead-contaminated soil.

Example Worksheet for Developing Recommendations

(Completed to show a biological monitoring action among children for potential lead exposure from soil)

Who is Involved in the PHA Process
Desired Outcome
Issues to Address
Who Will Implement?
Commitment Received
Timeline for Completion
Collect blood samples to test for lead exposure (for children ages 6 months to 7 years) Identify and test all at-risk children (will capture recent exposure; will not identify potential future exposures) Determine to what extent children are being exposed to lead If exposure is occurring, how can it be reduced or eliminated?

If exposure is occurring, can the site be distinguished as the source rather than other sources (e.g., lead paint in homes)?

If no elevated exposure is found, will that change the site conclusion category?

Local health department in cooperation with ATSDR Yes, with laboratory assistance provided by ATSDR Blood sample collection during Summer (time during which greatest soil exposures expected)