Health | Summer 2018

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PROMOTE

SOUTHWEST UTAH PUBLIC HEALTH FOUNDATION SUMMER 2018 NATURE THERAPY

HEALTHY SLEEP PART II

PG. 6

PG. 12

LOCAL HIKING PG. 18


HEALTH MAGAZINE | SUMMER 2018


LETTER FROM THE HEALTH OFFICER

We are celebrating our second year of being awarded a Utah “Best of State” medal for HEALTH Magazine. We started this publication because we wanted to have a venue where the message of wellness would be available to all of the residents in the five counties we serve. It can be challenging, even discouraging, to sort through the wide range of opinions about what it takes to keep us healthy. It turns out there are no “magic bullets” to prevent or cure all the ills of life, but part of our job is to stay current on research-based information that might come close.

we Encourage exercise by capitalizing on the amazing outdoor opportunities that surround us here in Southwest Utah.

Lifestyle-related disease rates are rising even as many of us, including our children, spend hours indoors gazing at a screen. In this, the 19th issue of HEALTH Magazine, we emphasize one of the most effective practices available when it comes to health and longevity: physical activity. We encourage exercise by capitalizing on the amazing outdoor opportunities that surround us here in Southwest Utah. We promote adequate sleep, good nutrition, and avoiding harmful substances. Many of our efforts are community based, but real change occurs with you as an individual. We hope you are inspired to be more active by exploring “our own backyard”. Sincerely,

David W. Blodgett, MD, MPH SWUPHD Health Officer & Director

Winner (2017, 2018) Utah Best of State Medal Community Development/Publication

SWUHEALTH.ORG | PAGE 3


COME FIND US...

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B E AV E R

IRON

75 West 1175 North 260 East DL Sargent Dr. Beaver, Ut. 84713 Cedar City, Ut. 84721 (435)438-2482 (435)586-2437

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The entire contents of this publication are Copyright ©2018 HEALTH (the magazine of the Southwest Utah Public Health Foundation) with all rights reserved and shall not be reproduced or transmitted in any manner, either in whole or in part, without prior written permission of the publisher. Health magazine hereby disclaims all liability and is not responsible for any damage suffered as the result of claims or representations made in this publication. Printed by Hudson Printing Company / Salt Lake City, Utah / hudsonprinting.com

HEALTH MAGAZINE | SUMMER 2018


Ask your doctor if Hiking is right for you. If you’ve tried Walking, then chances are you’ll benefit from Hiking. Hiking is specially formulated to combine the benefits of physical exercise with exposure to Fresh Air, Vitamin D, and Natural Aromatherapy. Hiking helps open airways for deep breathing, improves balance, helps control weight, and lowers risk of heart disease. Research indicates that Hiking even decreases symptoms of stress, anxiety, and depression. Best of all, Hiking is available free of charge. Initial investment in sturdy footwear is recommended, along with familiarization with basic safety precautions. Side effects may include loss of interest in electronic media and restlessness between excursions. Hiking may be addictive to some patients.

PREVENT

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NATURE. CHEAPER THAN THERAPY

By David Heaton, LCSW

PROMOTE

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8 By Dr. Blodgett, MD, MPH 16 THE 18 10 CLEARING VAPOR By Kye Nordfelt, MPA 21 AND YOUR 12 SLEEP HEALTH. PART II VALLEY FEVER

By Dr. Blodgett, MD, MPH

HEALTHY CHOICES WHEN EATING OUT

By WebMD

EXPLORING OUR PUBLIC LANDS 5 HIKES IN 5 COUNTIES HIKING IS FOR EVERYONE

PROTECT

22 24 26 28

WHAT'S IN YOUR BACKPACK? WILD VECTORS

ON THE COVER

Cover art by Joel Anderson & Michael Korfhage ©Anderson Design Group, Inc. All rights reserved.

By David Heaton, Editor

Used with permission from

SHAKE IT UP

www.ADGstore.com

Interview with Bill Lund, Geologist

THE AIR WE BREATHE

By Josh Poulson, EHS

SWUHEALTH.ORG | PAGE 5

QUESTIONS OR COMMENTS?

Email

info@swuhealth.org


Nature. Cheaper than Therapy By David Heaton, LCSW

MANAGING EDITOR

Thousands of tired, nerve-shaken, over-civilized people are beginning to find out that going to the mountains is going home. Wilderness is a necessity. -John Muir

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efore starting a career in public health, I was a full-time therapist at a behavioral health center. I saw firsthand how therapeutic interventions can help people with mental illness regain hope and stability. Yet there were those who didn’t seem to respond to traditional “talk therapy”. Almost out of desperation, I started taking a few of them walking or hiking along nearby trails and canyons. I saw them visibly relax and breathe deeper. We did less talking and more moving and observing in silence.

What conversations we shared focused on the present experience.The transformation wasn’t permanent, but it was noticeable. The concept of nature playing a role in the treatment of behavioral disorders is not new. Gardens and farms associated with mental hospitals were once commonplace in Europe. “Ecotherapy”, which is loosely defined but usually consists of tasks or exercises in an outdoor environment, has been well-established

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PREVENT

in our time. Therapeutic gardens, labyrinths, ropes courses, and teen wilderness programs would all qualify. There is a growing body of research suggesting that spending time in natural settings is beneficial to the body and brain. For many of us, it’s instinctive - which helps explain the idea of biophilia, or the human tendency to be drawn to nature and it’s many life-forms. Are we hardwired to spend time in the outdoors, and can that drive be subdued by the demands of modern living? The Encyclopaedia Brittanica, in a discussion on the biophilia hypothesis, notes that changes in human/nature interactions have been “made possible by the construction of enclosed and relatively sterile spaces, from homes to workplaces to cars, in which modern humans were sheltered from the elements of nature and in which many, particularly people living in more-developed countries, now spend the majority of their time.”

Restoration” theory in the 1980s, which has influenced environmental landscapers and designers ever since. They observed that people living in city environments are so constantly stimulated that their attention becomes exhausted. This can lead to mental fatigue, stress, and depression. Exposure to nature, on the other hand, captures our attention with no effort on our part. Being fascinated with the pleasant sights, sounds, and smells of natural settings gives our brain a break and restores our attention level. There is something about being in the natural world that opens our senses to something larger than ourselves. It amazes and delights humans from all cultures.

Beethoven took long walks in the woods of Vienna to keep his creative genius flowing. Many great thinkers, inventors, authors, and artists took long walks in the outdoors on a regular basis. They include Tchaikovsky, Nietzsche, Tolstoy, Freud, Dickens, Thoreau, Asimov, and Muir. Albert Einstein, himself Richard Louv, author of Last Child an avid walker, said “Look deep in the Woods, asserts that urban- into nature and then you will underized children with too much screen stand everything better”. time suffer from what he terms “na- There are many benefits of spendture-deficit disorder” (NDD). He ing time in nature, some more obviargues that time spent in nature is ous than others, including: essential for the overall health of people of all ages. • Enhanced immune system functioning A study published in the 2004 American Journal of Public Health • Reduced blood pressure found that children diagnosed with • Decreased risk of cardiovascular Attention-Deficit Hyperactivity Disdisease order (ADHD) had their symptoms • Reduced stress significantly lowered when put into • Reduced anxiety natural settings. After being taken on • Improved mood 20 minute nature walks, these chil- • Increased ability to focus, even in dren were able to behave just like children with ADHD their non-ADHD peers for the rest • Accelerated healing from surgery of the day. or illness Psychologists Rachel and Stephen • Increased energy level Kaplan came up with the “Attention • Improved sleep

• Improved self-awareness and positive body image • Improved cognitive functioning • Boosted results of exercise In the 1980s, the Japanese government became convinced that time spent in forests was so beneficial that it implemented a practice called “Shinrin-yoku”, meaning “forest bathing”. According to shinrin-yoku.org, “the idea is simple: if a person simply visits a natural area and walks in a relaxed way there are calming, rejuvenating and restorative benefits to be achieved...there have been many scientific studies that are demonstrating the mechanisms behind the healing effects of simply being in wild and natural areas.” The practice is now integrated into Japan’s healthcare system and is covered by insurance. Shinrin-yoku has spread to the United States, where Certified Forest Therapy Guides can be hired to lead participants on mindful walks through natural settings. I’m not one to discourage people from spending resources on interventions that help and heal. I’ve seen mental health therapy have remarkable results. But trust me, you don’t need a therapist to guide you through a meaningful experience in the outdoors. Whether we call it biophilia, instinct, or a spiritual yearning, all you have to do is show up and nature will take care of the rest. Enter the woods, follow a trail or stream, or climb a mountainside. Inhale the scent of a pine forest. Listen to the sound of water lapping a lakeshore or bubbling down a creek. Take in the inspiring views of red sandstone cliffs and deep canyons. Become familiar with your area’s natural places. Choose some favorites and invite others. Go often, you won’t get a bill!

The best remedy for those who are afraid, lonely, or unhappy is to go outside, somewhere where they can be quiet, alone with the heavens, nature and God. Because only then does one feel that all is as it should be. - Anne Frank SWUHEALTH.ORG | PAGE 7


valley fever By David W. Blodgett, MD, MPH

SWUPHD DIRECTOR & HEALTH OFFICER

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iving in Southern Utah has many advantages, including a beautiful landscape which invites us outside to participate in healthy activities. There are, however, several diseases unique to the desert southwest that we should be

aware of. Perhaps the most important of these is coccidioidomycosis, more commonly known as Cocci or Valley Fever. This disease is caused by inhaling the spores of a fungus called Coccidioides immitis. A respiratory illness may de-

HEALTH MAGAZINE | SUMMER 2018


PREVENT

velop, which infrequently can lead to chronic even after several courses of antibiotics do not disease. improve the symptoms of the disease. Many physicians consider a Valley Fever diagnosis Coccidioides is fairly pervasive in specific re- when longstanding upper respiratory infecgions (Arizona, New Mexico, small areas of tions don’t respond to antibiotics. Texas and California, and the southwest corner of Utah). Almost all cases of Valley Fever Occasionally, Valley Fever becomes chronic in Utah originate in our district (about 60 per and can cause severe lung infections. Antifunyear). gal medications are recommended for these cases and usually resolves the illness within Coccidioides spores can remain inactive in three to six months. Valley Fever can develop the top layer of desert soil, then spread when into meningitis which often requires lifelong the soil is disturbed. Dust produced by wind, antifungal treatment. Most infections heal construction, or vehicles can cause infection if completely, but one out of every 1,000 cases enough spores are inhaled. Fortunately, most will suffer permanent damage to their lungs or infected people will experience no symptoms nervous systems. at all, and Valley Fever is not contagious. Generally, the younger you are when exposed If symptoms do occur, they take between one to Coccidioides, the better your immune systo four weeks to appear. The most common tem is able to successfully fight off infection. symptoms of Valley Fever include chest pain, Most people who have lived in this area for cough (possibly a long time have producing bloodprobably been extinged phlegm), posed to the spores fever, night and are immune to sweats, headache, Valley Fever. muscle aches, joint stiffness, and loss I worry most about of appetite. Swellunexposed moveing and painful red ins or travelers, eslumps on the lower extremities can also occur. pecially older adults. You’re also more likely to develop a serious Valley Fever infection If the disease is able to spread throughout the if you have a weakened immune system due body, a rare but serious condition called dis- to anti-tumor necrosis factor (TNF) therapy, seminated coccidioidomycosis can develop; cancer, chemotherapy, steroid medications, causing a change in mental status, enlarged heart and lung conditions, HIV/AIDS, organ or draining lymph nodes, joint swelling, dif- transplant, or pregnancy (especially in the ficulty breathing, neck stiffness, sensitivity to first trimester). light, weight loss, and skin lesions on the face. Valley Fever is one of the few drawbacks of Most symptoms of Valley Fever will go away living in Southern Utah that I’m aware of. within a few months without any treatment. However, knowing how this disease spreads Valley Fever can be difficult to distinguish and what the symptoms are can lead to rapid from bacterial reperatory infections, thus it diagnosis and treatment for those who would can sometimes be mistaken for pneumonia, be most dramatically impacted by it.

almost all cases of valley fever in utah originate in our district.

SWUHEALTH.ORG | PAGE 9


clearing the vapor By Kye Nordfelt, MPA

SWUPHD HEALTH PROMOTION DIRECTOR

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mily (name changed for confidentiality) was devastated when she discovered her son’s e-cigarette use (also called “vaping”). She had already noticed changes in his grades and mood, and had become concerned about his friends. One day, when he was out of the house, she quietly entered his room and found a small black box, a little thicker than a cell phone. It had a screen on the side that lit up when some buttons were pushed. With the box was a container that looked like a bottle of eye drops. Inside the bottle was a liquid that smelled like watermelon. Was her son’s recent use of strong cologne meant to hide the smells from the device? Emily and her husband had raised their son in a religious home and had taught him to avoid alcohol, tobacco, and harmful drugs. Now she sat stunned and depressed, unsure of what to do. Where did he get the device? How harmful was it? How should she approach her son?

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Emily searched the internet for information regarding e-cigarettes but found conflicting information. She consulted with her ecclesiastical leader, but he knew less than she did. Finally, a family member referred her to a new online course developed by the Southwest Utah Public Health Department (SWUPHD), called “Clearing the Vapor”. It provided the information she was looking for.

Introducing "Clearing the Vapor"

Clearing the Vapor (CTV) is a free online course that helps parents and their children explore what is known about e-cigarettes, which are defined as electronic devices that deliver nicotine and other substances through vapor that is inhaled into the lungs. CTV is designed to read like social media with videos and limited text. After viewers login, they can browse through specific chapters or take the full course, which takes about an hour. Parents, teens, educators,

church leaders, and court staff can take the course. Quizzes are given along with a certificate showing proof of completion. Those who finish the CTV course will be able to: • Understand the alarming increase in teen vaping in our community • Summarize the current research about the harms of youth vaping • Discover how e-cigarette companies target teens • Identify tools caregivers can use to help raise tobacco-free kids “Clearing the Vapor was worth the time,” Emily said. “I learned that nicotine has a more harmful effect on the developing brains of adolescents, and that even vapes with no nicotine have risks. I also found out that teens who try vaping are two to four times more likely to start smoking traditional cigarettes.”

SWUHEALTH.ORG | PAGE 11

Teen vape use has increased 300% over the past few years in Southwest Utah, with about 40% of high school seniors reporting having vaped at least once. Emily never thought her son would be part of those statistics and didn’t know where to turn for help until she found the CTV resource.

Resources to help parents

To access Clearing the Vapor, visit swuhealth.org/ctv. Parents struggling with a child’s use of e-cigarettes - or any drug (including alcohol) - can also get help by calling 1-855-drugfree or visiting drugfree. org. This free service provides advice from trained specialists who will help parents find answers and make an action plan. Kye Nordfelt is the developer of the Clearing the Vapor course and can be reached at 435-986-2593 or knordfelt@swuhealth.org to answer any questions about teen vaping.


sleep & your health. Part II By David W. Blodgett, MD, MPH

SWUPHD DIRECTOR & HEALTH OFFICER

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n the last issue of Health Magazine (Spring 2018), we talked about the importance of sleep, which may be just as important to overall health as exercise, eating right, and not smoking. Adequate sleep sharpens memory, attention, and creativity. It improves work performance and heart health while reducing inflammation, anxiety, and stress. This article will focus on the quantity and quality of good sleep habits. Unfortunately, the statistics on sleep dysfunction in the United States are sobering. Between 50 and 70 million US adults have a sleep disorder, with 48% reporting snoring and 38% reporting unintentionally falling asleep during

the day at least once in the preceding month. Nearly 5% admit nodding off or falling asleep while driving at least once in the preceding month. Drowsy driving is responsible for 1,550 fatalities and 40,000 nonfatal injuries annually in the United States. Insomnia is the most common sleep disorder, with 10% of adults suffering with chronic insomnia, and 30% having short-term episodes. Nearly 40% of adults report not getting enough sleep at night, meaning less than 7 hours of sleep per 24-hour period. It is thought that 100,000 deaths occur each year in U.S. hospitals from medical errors in which sleep deprivation was a contributing factor.

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How much sleep should we be getting? The National Sleep Foundation recently changed their recommendations for how much sleep is needed every night, broadening the range by an hour in many cases.

Adults: 7-9 hours Teenagers: 8-10 hours Children 6–12 years: 9-12 hours Children 3–5 years: 10-13 hours

(including naps) Children 1–2 years: 11-14 hours (including naps) Infants 4-12 months: 12-16 hours (including naps) While these are the general recommendations, it is important to recognize that individual sleep requirements may be different. Pay attention to your own needs by assessing how you feel on different amounts of sleep. Regardless of what that may be, ask yourself these questions (be honest with yourself!): • Am I productive, healthy, and happy after seven hours of sleep? Or do I need a good nine hours to be able to function well? • Do I depend on caffeine to get through the day? • Do I feel sleepy when driving? • When I have the opportunity to sleep unrestricted (on weekends, holidays, vacations, etc.), how long do I sleep to feel rested and rejuvenated? Pay careful attention to your mood, energy, and health after a poor night's sleep versus a good one. Ask yourself, "How often do I get a good night's sleep?" Like nutrition and exercise, sleep is a critical component of overall health. Do you want to be able to fall asleep (and stay asleep) better?

Try these proven tips:

1. Stick to a sleep schedule. Go to

bed and wake up at the same times every day, even on the weekends. This regulates your body's internal clock, helping you fall asleep and stay asleep for the night. 2. Have a bedtime ritual. A calming routine right before bedtime can help you get to sleep and stay asleep. Try reading a book, taking a shower, or anything else that takes your mind off the day and helps you relax. 3. Avoid naps. If you have trouble falling asleep at bedtime, avoid naps, especially in the afternoon. 4. Exercise daily. Vigorous exercise is best, but even light exercise is better than no activity. You can exercise any time of day unless you find that evening activity affects falling asleep. 5. Evaluate your room. Design your sleep environment to be sleep-friendly. Studies show that you sleep better in a cool room that is free from noise and light. 6. Are you comfortable? Make sure your mattress and pillows are comfortable and supportive. 7. Manage your exposure to light. Expose yourself to sunlight in the morning but avoid bright light in the evening. This will keep your circadian rhythm balanced. Blue light from the screens on televisions and electronic devices have been shown to decrease melatonin levels, reducing your ability to fall (and stay) asleep.

8. Avoid alcohol, cigarettes, and heavy meals in the evening. Alcohol, cigarettes, and caffeine can disrupt sleep, as will indigestion from large or spicy meals. Avoid eating heavy meals for two to three hours before bedtime. Try a light snack 45 minutes before turning in if you’re still hungry.

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9. If you can't sleep, leave the bedroom. Go

to another room and do something else until you feel tired. Your mind and body should associate your bedroom with sleep, not restlessness or looking at screens. 10. Get help. If you’ve tried everything you can and are still having trouble sleeping, don’t hesitate to seek medical help. Your doctor should be able to provide additional solutions and resources to get you back on track. And now a word about night-time screen use. Smartphone technology and 24/7 access to information and entertainment is impacting sleep routines like never before. However, you can do something about that. Recently, researchers asked 175 participants to try an experiment that might sound more like a nightmare to some people: they were asked to banish cell phones from their bedrooms for 3 months. These participants were rated before and after the study and compared with 170 people who kept their devices at their bedsides during the same time. The results showed significant changes in those who banished their phones, including improved ratings of restful sleep, happiness, quality of life, and relationships, along with decreased problems with anxiety and addictions. In fact, over 90% of the participants said they intended to keep their cell phones out of the bedroom. Similar results are reported in people who take breaks from watching the news or engaging in social media. It seems clear that being constantly online takes a toll on our need to get adequate restful sleep. This may be a hard pill to swallow, but keeping your smartphone out of your bedroom may be one of the best things you can do for your well-being. It will be a hard habit to break for some people, but prioritizing adequate sleep is vital to your health and worth the effort.


It’s not uncommon for Americans to eat out several times a week, which can contribute to diabetes, obesity, high blood pressure, and heart disease. Eating establishments are taking notice of the demand for healthier food.

healthy choices when eating out From WebMD.com

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any restaurants offer delicious, heart-healthy meals. These tips will help you make eating out healthy and enjoyable:

HEALTH MAGAZINE |SUMMER 2018


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Before You Order

• If you are familiar with the menu, decide what to order before entering the restaurant. This tactic will help you avoid any tempting foods that may not be as healthy. • If you are trying a new restaurant, take time to study the menu so you can make the best choices. • Have the waiter remove temptations (such as the bread basket) from the table. • Drink two full glasses of water before your food arrives. • Avoid foods described as buttery, buttered, fried, pan-fried, creamed, escalloped, au gratin (with cheese), or a la mode (with ice cream). • If you do eat bread before your meal, choose melba toast or whole-grain rolls without butter or margarine.

Salad Tips

• When choosing from a salad bar, avoid items like grated cheese, potato salads, cream dressings, bacon bits, and croutons. • Use a squeeze of lemon instead of dressing on salads. Or try rice vinegar or balsamic vinegar. • If you opt for dressing on your salad, order the dressing on the side. Dip your salad fork into the dressing, then into the salad. You will consume less dressing if you just get a taste of it on each mouthful of salad rather than pouring it over the salad. Originally titled High Cholesterol: Healthy Choices When Eating Out, (WebMD Medical Reference/Reviewed by James Beckerman, MD, FACC) © 2018 WebMD, LLC. All rights reserved. Used with permission.

Looking for healthier places to eat?

Check out this list. Recently, 10 local restaurants were awarded the “Good For You, Dixie!” seal of approval. These restaurants offer menus with healthy options that often include caloric information. They also adhere to 80% or more of the standards set by Intermountain Healthcare dietitians, which include amounts of fat and sodium, types of beverages offered, and healthy food promotion. Recipients can have the seal placed on the winWhen You Order • Order foods that are steamed, broiled, dow or door of their establishment.

grilled, stir-fried, or roasted. • Order potatoes baked, boiled, or roasted instead of fried. Ask the server to leave off the butter and sour cream. • Order first so that you will not be influenced by others’ choices. • For appetizers, order broth-based soups such as minestrone or gazpacho instead of creamy soups or fried finger foods. • Choose seafood, chicken, or lean red meat rather than fatty or processed meats. Remove all visible fat from any meat. • Ask for steamed vegetables instead of fries. • Ask for the sauces and dressings on the side so you can control how much you eat. • Ask the server about ingredients or preparation methods for the dishes you're not familiar with. • For dessert, order sorbet or fresh, seasonal fruit without whipped cream or a topping.

Intermountain Healthcare, the St. George Area Chamber of Commerce, and the Southwest Utah Public Health Department are sponsoring the award as a way to help the community become aware of healthier food choices when eating out.

2018 “Good for You, Dixie” award recipients: Ahi’s Taste of Asia Bella Marie’s Pizzeria Brick Oven Katering Koncepts Jamba Juice Jimmy John’s Teriyaki Grill Tropical Smoothie Twisted Noodle Cafe Viva Chicken If you are interested in applying for the award next year, contact Courtney at crasmussen@swuhealth.org for more information.

SWUHEALTH.ORG | PAGE 15


exploring our public lands Like Idaho and Nevada, most of Utah’s land is federally owned and generally open to public access. Agencies which act as custodians to these lands include the Bureau of Land Management (BLM), the Forest Service, and the National Park Service. If you’re reading this in Southwest Utah, you are likely only a short drive to areas that visitors from around the world come to visit. Have you taken advantage of the incredible landscapes in your own backyard?

Bureau of Land Management

The BLM manages almost 23 million acres of public land in Utah. “Recreational opportunities are definitely a high priority”, says Nick Howell, Public Affairs Director for the BLM Color Country District. “We’ve seen an increase is visitors to our part of the state and are always looking for ways to improve their experience. The BLM works with volunteer groups to develop marked trails for multiple use. In Iron County, for example, there are now over 25 miles of trails between the Three Peaks, Thunderbird Gardens, and Iron Hills systems which are great for hiking and biking.” The BLM works closely with other agencies in joint efforts to develop areas on “both sides of the fence”. Kanarraville Falls, for example, is situated within an area that requires the cooperation of the BLM, Iron County, Kanarraville, and school trust lands. Other areas of interest include the Rock Corral Recreation Area (northeast of Milford), Parowan Gap, Hamblin Valley, Canaan Mountain, Utah Hill, Red Cliffs, and Baker Dam. “While some HEALTH MAGAZINE |SUMMER 2018


PROMOTE

of these places have become popular and crowded, there are plenty of others on BLM land that are off the beaten path if you have the time and are willing to travel a little further,” explains Howell. He emphasizes that preparedness is key. “Travel with plenty of water and food. Check maps to plan where you’re going without trespassing on private property. Check weather conditions and make sure you have a vehicle that can handle rugged or muddy road conditions. A lot of BLM areas are far from civilization with limited or no cell coverage. Make sure you're self-sufficient.” Permits are usually not needed with the exceptions of large group events or commercial operations. More information can be found online at blm.gov/utah. You can also visit one of the BLM field offices in Cedar City, St. George, and Kanab to ask questions and purchase hard-copy maps.

Dixie National Forest

The homepage for the Dixie National Forest boasts “hundreds of miles of trails for hiking and backpacking. The landscape of the forest is extremely varied in elevation, plant life, and geology. Hike in the rocky pinyon and juniper forests, through lush meadows full of wildflowers, through rugged lava fields, to high mountain lakes, or to the rim of mesa tops with scenic views of the lower red rock canyons below.” Established in 1905, Dixie National Forest is the largest national forest in Utah, nearly 2 million acres in size, including 83,000 acres of designated wilderness area. Other than the Pine Valley Recreation Area, all forest land is open to recreation free of charge. Visit fs.usda.gov/dixie, click the Take a Hike icon to get access to over 175 day hikes!

Zion National Park

Zion National Park is one of the most visited parks in the nation. It was the first in the state and saw over 4.5 million visitors in 2017. Known for its sheer sandstone cliffs that tower over the Virgin River and epic hikes like the Narrows and Angels Landing, Zion covers 150,000 acres of diverse geography. The park can be crowded during tourist season, requiring shuttles into the park to access hiking trails. Find out more at nps.gov/zion.

Bryce Canyon National Park

Bryce Canyon National Park features huge natural amphitheaters filled with red-orange hoodoo formations. It was designated as a national park in 1928 and contains 35,000 acres. Bryce gets roughly half the number of visitors that Zion does. Hikers can take the popular Navajo Trail - a short but steep loop through the hoodoos - or a variety of others, including the lesser known Swamp Canyon Trail, a 4.3 mile day hike. Learn more about Bryce Canyon at nps.gov/brca Also worth visiting are Cedar Breaks and Grand Staircase-Escalante National Monuments, not to mention state parks like Snow Canyon, Coral Pink Sand Dunes, Kodachrome Basin, and Escalante Petrified Forest. SWUHEALTH.ORG | PAGE 17


5 Hikes in 5 Counties

Southwest Utah is a hiker’s paradise, with hundreds of miles of trails through deserts, forests, and mountains. Here’s a sampling of some local trails:

Garfield County: Cassidy Trail Submitted by Clint Albrecht

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njoy Bryce Canyon scenery without the crowds. From Highway 89 turn east onto Highway 12. Go approximately 4.5 miles, pass the Red Canyon Visitor Center, and park at the Red Canyon Trailhead on your left. Watch closely or you may miss it. The trail is accessible to hikers, bikers, and horses. It is believed to have been used by the famous outlaw Butch Cassidy in his escapes from lawmen. You will pass red hoodoos and large, old ponderosa pines as you wind through the bottom of the wash and eventually climb to scenic vistas that culminate at Brayton Point. This trail is part of a larger, well-marked trail system where you can hike from 4 to 16 miles, round trip. The trail is rated as moderate and is mostly open to the sun with pockets of shade. Take plenty of water. CASSIDY TRAILHEAD (PHOTO COURTESY OF GIRLONAHIKE.COM) HEALTH MAGAZINE |SUMMER 2018


PROMOTE

Iron County: Lightning Switch Trail Submitted by David Heaton

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rom Main Street in Cedar City, turn east on 900 North (by La Fiesta restaurant). Stay left at the next junction onto a dirt road. You'll see the golf course clubhouse on the right. Drive for about a mile, passing a flood control dike on your left, until you reach the Thunderbird Gardens parking lot. Look for the trailhead sign. Lightning Switch is one of the newer sections of the Thunderbird Trail System and is about 5 miles round trip. Begin hiking along the Ghost Flats trail, then turn left at the sign for Lightning Switch, which winds up though a juniper forest along continuous switchbacks. The trail ends when it meets the Ghost Flats section again. Return the way you came or make a loop by turning right (west) on Ghost Flats Trail for a shorter trip back. KIDS ON THE LIGHTNING SWITCH TRAIL

Kane County: Mansard Trail Submitted by Lexie Little

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rom Kanab, drive east on Highway 89 for 6.5 miles. Just past milepost 59, turn left onto Vista Drive Road, then right on Grande Vermillion Avenue, left on Coyote Canyon, left on Rocky Ledge Lane, then through the gate on road #105. Stay right when the road splits and park at the trailhead. There will be signs leading the way. This trail is four miles round trip. Be sure to bring plenty of water and be prepared for hiking in hot weather. Previously very steep and strenuous, the Mansard Trail is now more family friendly after being redesigned and improved. The trail leads to the Mansard petroglyph site. Thought to date back to the ancient Anasazi period, the unique symbols are carved into a sloping sandstone floor, protected by an overhanging cliff. The straight grooves in the stone have never been found in any other site. Please do not walk on or touch the petroglyphs. A FAMILY HIKES THE MANSARD TRAIL (INSET: PETROGLYPHS)

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Beaver County: Skyline Trail Submitted by Debbie Cox

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rom Beaver, drive east up the canyon on Highway 153. After 16.4 miles, turn left on the road to Big John Flats (Forest Road 123). Continue for 4.8 miles on this well-maintained dirt road to the Skyline Trailhead, where you’ll find a parking area with a restroom. The hike is about 11 miles point to point if you want to plan a shuttle, or you can turn back whenever you choose. The hike goes up and down at elevations between 10,000 and 12,000 feet with some steep grades. This is an amazing trail with many access points to other trails and beautiful views of the Tushar mountains, wildflowers, and wild Rocky Mountain goats. There is little to no cell phone service. Be sure to drink plenty of water and be aware of the signs and symptoms of altitude sickness. These include headache, nausea and dizziness, loss of appetite, fatigue, and shortness of breath. If this happens, then stop and rest. Head back if it gets worse.

VIEW OF DELANO PEAK FROM THE SKYLINE TRAIL

washington county : whipple Trail Submitted by Dave Nelson

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ravel to Pine Valley and turn left at the Chapel junction (onto Pine Valley Road). Continue east and follow the signs to the Whipple Trailhead. This is a moderate to strenuous 12 mile hike (round trip) that takes about 6 hours. The first quarter mile of this hike winds through a lush forest of pines and aspen trees. You will soon enter official wilderness area and begin a moderately steep switchback climb to the first saddle before descending into Hop Valley, filled with thick aspen groves and a beautiful stream. You are now in the heart of the Pine Valley Mountains, with their fascinating hoodoos, pinnacles, and towering cliffs. From Hop Valley, the trail begins a gradual climb that soon turns into a steep ascent, eventually reaching a forest plateau section at 9,200 feet. Don’t forget to stop and admire the incredible views of the interior of the mountains. From the plateau, the trail descends into Whipple Valley, probably the largest meadow in the Pine Valley range. There are two creeks which keep this meadow green and attractive. You should now be at the junction to the summit trail. Return by the same route.

MEMBERS OF THE SUNRIVER HIKING CLUB MAKE THEIR WAY UP THE WHIPPLE TRAIL

HEALTH MAGAZINE |SUMMER 2018


PROMOTE

Common Sense

hiking tips

• Virtually anyone can hike. Just make adjustments for age, ability, health conditions, and experience. Start with short, easy hikes and work your way up. • Research your route and get tips from others who have done it. Bring a map if possible. Look for and follow trail markers. • Check weather conditions. Wear clothing appropriate for the season but be prepared for unexpected weather. Reconsider your plans if storms, flooding, or extreme temperatures are in the forecast. • Don’t travel alone and let others know where you’re going. Allow for plenty of leeway when estimating when you’ll finish or return. • Do yourself a favor by taking the right gear (see next page) • Bring adequate food and water. Stay hydrated. Purify/filter water from lakes, streams, or springs. • Stay on established trails. Be considerate of other hikers when passing. Don’t kick or throw rocks when there are trails below you. Carry out all your trash and go a step further by picking up trash left behind by less thoughtful hikers. • Enjoy viewing wildlife but keep your distance. • Educate yourself on what to do if you get lost or injured in the outdoors.

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what's in your backpack? supplies for a day hike 13

1. Water (bring plenty!) 2. Food (lightweight & calorie-dense) 3. Hat (protection from sun/rain) 4. Jacket (lightweight extra layer) 5. Toilet Paper (essential when nature calls) 6. Trash Bags (for packing out garbage) 7. Chapstick (moisturizer & UV protection) 8. Sunglasses (UV protection for eyes) 9. Sunscreen (UV Protection SPF 30-50) 10. Insect Repellent (30% DEET) scarf, headband, coolant when 11. Bright Bandana (head wet and worn around neck, signaling) 12. Camera 13. Field Notes (hike documentation) 14. Phone

Emergency supplies 16

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15. Portable Phone Charger (extend your phone usage) 16. Water Filter (for drinking from streams, lakes, etc.) 17. Poncho (lightweight rain protection) 18. Space Blanket (lightweight warmth & signalling) 19. Flashlight (in case you're out after dark) 20. Lighter/matches (warmth, light, & signaling) 21. Whistle (signalling) 22. First Aid Kit (for cuts, blisters, splinters, etc.) 23. Knife

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wild vectors By David Heaton, Editor

SWUPHD EDITOR

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any of us enjoy venturing into the outdoors but those who want to enjoy Southwest Utah’s outdoor opmay hesitate for fear of becoming the victim of a portunities while lowering their risk of contracting an unpleasant - or potentially serious - disease. wild predator.

What are the chances of that? Virtually none. While encounters involving teeth and claws occasionally happen, death by wild animal is extremely rare. In Utah’s recorded history, there has been only one fatality from a bear attack. There has been one death from a rattlesnake bite. People killed by a mountain lion? Zero. You’re more likely to be killed by a deer - the deadliest animal in America - by hitting one with your car. The tiny mosquito is more dangerous than large predators in our state, acting as a vector for West Nile Virus which caused 16 deaths since the disease entered Utah in 2003.

West Nile Virus Vector: Mosquitoes. Since it first arrived in the U.S. in

1999, West Nile virus (WNV) has spread throughout the country. In Utah, the disease is mostly transmitted through the bite of mosquitoes in the Culex family, known to feed at night. WNV is not contagious between humans. Only 20% of people infected will experience symptoms that include fever, headache, body aches, abdominal pain, nausea and vomiting, swollen lymph glands, and rash. Less than 1% of cases will develop serious neuroinvasive symptoms that can lead to hospitalization and death. Prevention includes wearing repellent (containing 30% DEET), wearing long sleeves shirts and long pants, and avoiding being outdoors at night during mosquito season.

In the world of diseases, a vector is anything that carries a pathogen into another organism, and usually refers to insects and other arthropods. Fortunately, while deaths from diseases caused by vectors in nature are more common than those resulting from wild animal Tularemia (Rabbit Fever) attacks, they are also very rare. The following diseases Vectors: Deer Flies, Infected Animal Tissue. Tularemia and their wild vectors are presented as a precaution for is a bacterial infection which can take several forms;

HEALTH MAGAZINE | SUMMER 2018


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typically attacking the skin, eyes, lymph glands, and lungs. Common causes are deer fly bites and exposure to infected animals through hunting or skinning. Symptoms include fever, ulcers at the bite, eyes, and mouth, swollen lymph glands. There are other symptoms specific to the type of tularemia, but a doctor should be consulted if you develop ulcers and swollen glands after a bite or handling a wild animal. It can be difficult to diagnose, but is treatable with antibiotics, and most patients completely recover. Protect yourself by wearing DEET repellent against deer flies, using gloves when trapping or skinning animals, and cooking game meat thoroughly.

of antibiotics, the risk of death from plague infection is low when treated promptly. The last plague death in Utah was in 2015, the first in 35 years. Utah’s dry climate doesn’t support a significant flea population, but plague can be found in prairie dogs, and squirrels, among other rodents and mammals. The only case in Southwest Utah in recent history involved a Washington County man in 2000, who fully recovered. Prevention includes wearing DEET repellent (30%), avoiding human and pet contact with rodents, and wearing gloves when handling/skinning potentially infected animals.

brush, grass, or leaves, you may pick up some unwelcome passengers. Ticks wait on vegetation for a chance to attach themselves to passing humans and animals so they can bite and feed on their host. They will stay in place for hours to days during feeding. Some tick species in Utah are known to cause CTF (viral) and RMSF (bacterial) infections in humans. Symptoms for both diseases are similar: high fever, severe headache, chills, and nausea, often accompanied by a rash. CTF will usually resolve on its own, but RMSF can be serious if not treated with antibiotics, so get medical care if you’ve had a tick bite followed by a fever, just to be safe. As a side note, Lyme disease is the most common infection spread by ticks in the U.S. but is not known to be established in Utah. Most Utahns with Lyme disease were bitten by a tick in another state, and studies continue to look into local tick species that may potentially carry the bacteria. Prevent tick bites by staying on cleared trails, wearing long pants, and using DEET repellent. Check yourself for ticks after hiking or camping. You can remove ticks from your skin by using fine-tipped tweezers to grasp the tick as close to the skin as possible and pulling straight upward with steady, even pressure. Disinfect with alcohol and watch for symptoms over the next few weeks.

inflammation preceding death. The best course of action if someone is bitten by a bat (or any possibly rabid animal) is to thoroughly wash the wound and capture the animal, then contact the local health department to arrange testing for rabies. If the results are positive, an effective vaccine series is administered. This action may also be taken as a precaution if there was contact with a suspected rabid animal that could not be tested. Remember to not approach or handle wild animals especially bats - that appear ill or show unusual behavior.

Rabies Colorado Tick Fever (CTF), Rocky Mountain Spotted Fe- Vector: Bats. Rare, but by far the most fatal disease on the list. Rabies is a virus which is 99% fatal once ver (RMSF) signs appear; which include fever, hyperactivVector: Ticks. When you explore terrain covered with clinical ity, progressive paralysis, psychosis, coma, and brain

Plague Vectors: fleas, rodents. This infamous disease, caused

by the bacteria Yersinia pestis, was known as the Black Death when it killed over 50 million people in 14th century Europe. Millions more have died from the plague in outbreaks throughout history. It can be contagious and is a potential bioterrorism agent. Once bitten and infected, victims may experience the sudden onset of fever, headache, chills, and weakness. Buboes (swollen lymph nodes) form, which is where the name bubonic plague comes from. Thanks to the development

Giardiasis Vector: Fecal particles in water or food. Giardiasis is

caused by Giardia lamblia, a microscopic parasite. It is the most commonly diagnosed intestinal parasite disease in the United States. It is spread by ingesting contaminated water and food or from other people or animals. Symptoms include diarrhea and abdominal pain, and weight loss and dehydration can occur. People often pick up Giardia parasites while travelling to underdeveloped countries or after drinking from natural water sources like streams, rivers, lakes, and springs. Nearly all wilderness-related giardiasis are linked to water as the source. Other than that, most cases are caused by person-to-person contact and usually involve poor hygiene practices. Prevent becoming a host by washing hands thoroughly, especially after exposure to a potential source. Do not drink from streams and lakes without boiling or filtering first. Avoid swallowing water when swimming or traversing them. Although some of these illnesses can be serious, all are rare. And that’s the good news. Take common sense precautions and enjoy exploring the outdoors. The benefits to your health will far outweigh the risks of getting a wild vector-borne disease. Or being eaten by a bear.

SWUHEALTH.ORG | PAGE 25


shake it up Interview with Bill Lund

RETIRED SENIOR SCIENTIST WITH THE UTAH GEOLOGICAL SURVEY While growing up in the Coeur d’Alene mining district of northern Idaho, Bill Lund had an 8th grade earth science teacher who opened up a world of volcanoes, glaciers, and fault lines. He knew from that point on that he wanted to be a geologist. After earning a geology degree from the University of Idaho, Bill moved his family to Phoenix, Arizona to work in engineering geology. He worked for several years as a consultant for nuclear power plants and pipelines before joining the Utah Geological Survey (UGS). Although he retired last October after 36 years with the UGS, he is currently working (on emeritus status) to update hazard guidelines for radon gas.

HEALTH Magazine: How can we prepare for an earthquake?

Bill: Utah is fairly savvy about earthquakes these days. Unreinforced brick or masonry buildings have no ability to flex and can collapse in a large earthquake, so older structures are slowly being stabilized or replaced. This would be particularly important in a place like downtown Salt Lake City. Single family wood-frame homes are some of the safest buildings you can be in during an earthquake. They’re

flexible and will move around without collapsing, and metal straps secure them to the foundation. You may not have a lot of house left when it's over but you'll most likely get out alive. To minimize damage and injury you should secure water heaters, bookshelves, and anything else that would fall or tip over.

How should we respond after an earthquake?

The most important thing to remember if you feel an earthquake is to drop

HEALTH MAGAZINE | SUMMER 2018

to the floor, take cover if you can, and hold on to something until it’s over. People wonder if they should turn the gas off to their house or not. If you don't smell it, dont mess with it. If everyone turned off their gas whether they needed to or not, it could take the utility company days, if not weeks, to get everything operating again. You should have a family plan of how you would communicate and find each other after an earthquake. Also, how would you take care of your animals? Would you be prepared to evacuate or shelter in place?


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Standard wisdom is to have a 72-hour kit for each person that would help you survive for three days. It should be kept in your car or where you can easily get to it in case of evacuation. But if you’re able to stay in your home, the stark reality is that three days of supplies aren’t even close to adequate after a major disaster. You'll need to be able to function longer than that. In this state, where the LDS religion encourages food storage, you'll be in good shape if you have it and can get to it. Being prepared for large earthquakes requires staying current on our plans and supplies, but it’s easy to forget about it when the recurrence of quakes isn’t close enough to keep us reminded. Our rate for quakes here is about a tenth of California’s.

earthquake in the Salt Lake or Provo segment of the Wasatch fault would result in thousands of deaths and injuries and major structural damage. You may wonder why so many Utah communities are built right on top of active faults. The reason is that they are the type of faults that create mountain ranges, which have water runoff. In an arid state, you’ve got to live at the base of these mountains if you want to be close to a water source. This describes places like Ogden, Brigham City, Bountiful, Salt Lake City, Provo, and all the way down to Cedar City and St. George.

Tell us about earthquake activity in our part of the state

An earthquake near St. George in 1992 (5.8 magnitude) was the state’s biggest in decades, and would have caused a lot more damage if it occurred in Salt Lake City. We can expect a quake in the 5-6 range about every 14 years. They aren’t big enough to rupture ground surface, but can knock over anything not strapped down or secured.

The Hurricane fault is the biggest and most active fault we have down here. The uplift in the earth east of the Hurricane fault has created the Hurricane Cliffs, which include the mountains east of Cedar City down to What determines an earthquake’s sever- Toquerville. As you drive south from Cedar City to the Black Ridge, you’ll pass through a rock cut. The volcanic rocks you see by the road on your ity? You’re going to be affected by how big it right are from the same formation on top of the high cliffs to your left. The is, how close you are to the epicenter, the fault continues through Hurricane and on to Arizona. terrain, and your immediate surroundings. Magnitude is a measurement of how There are other faults we don’t know much about. They go right through much energy is released by an earthquake. places like Beaver, Parowan, Enoch, and Enterprise; all doing their own The Richter scale can measure the size thing. of earthquake waves up to a 7.5 magnitude. We now use the moment magnitude What are the most dangerous geologic hazards in Utah? (Mw) scale, which can also measure larger So far, it’s not earthquakes - although those have the most potential for quakes. An earthquake of magnitude 6 is 32 catastrophic damage. And it’s not volcanoes, although we have many times stronger than a 5, for example, while dormant ones that could potentially become active over time. As far as a magnitude 7 quake releases 1000 times fatalities are concerned, several people have died in landslides and debris more energy than a 5. The largest earth- flows and 101 have died in floods. But over 5300 people are estimated quake ever recorded, by the way, was the to have died from radon exposure since 1973, making it the most deadly the Great Chilean Earthquake in 1960, at a geohazard in Utah. 9.5.

What is Utah’s earthquake risk?

We have the Wasatch fault, which separates the Great Basin and the Colorado Plateau. It’s the largest active earthquake fault in the Intermountain West. We expect big quakes there every 500-1000 years, and we’re about due for the next one. It could strike tomorrow or in 200 years. There are roughly 250 active faults in Utah. You could think of them as alarm clocks, all wound up and set to ring. But they are running at different speeds and not keeping the same time. Which one's going to ring first?

What is radon?

Radon is a naturally occurring radioactive gas that is a byproduct of uranium. It is the second leading cause of lung cancer after smoking. Homes can be tested for radon and retrofitted with a system to mitigate the problem if the results are high enough, although there is no known lowest threshold for safety. This can be expensive, so there may be some merit to installing systems in all new construction in the future.

Any final words?

In all my years of studying quakes, faults, and other features of the earth, I’ve realized that we understand so little about mother nature, and most geologists are continually amazed at what they find.

The University of Utah Seismology Stations monitor earthquake activity The effects of a magnitude 7 quake in a for the state and Yellowstone National Park. You can visit their website at sparsely populated area would be of re- quake.utah.edu to see a map of every quake over the last few hours, markable scientific interest, but the same days, or weeks, including magnitude.

SWUHEALTH.ORG | PAGE 27


the air we breathe By Josh Poulson

SWUPHD ENVIRONMENTAL HEALTH SCIENTIST

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ir is the most essential need to sustain human life, yet we don’t often think about how affected we are by it. When it’s hot we want it to be colder and when it’s cold we want it to be hotter. When we exercise we need more of it and when we sleep we use less of it. Air contains about 21% oxygen, which is needed for human metabolism as well as the combustion of fuels like coal and natural gas that power our homes, cars, and power plants. When the air looks hazy outside, it’s because there is more particulate matter (PM) in the air. These particles can come from human sources like vehicle emissions, wood burning stoves, and industrial pollution or natural processes like forest fires, strong windstorms, and unusual weather patterns. Polluted air can clear up in a relatively short amount of time after an event like a windstorm as fine sand and dust particles settle back to the ground. Contamination lasts longer when the buildup from daily activities like driving and industry becomes trapped by cold air, a condition known as inversion, which is especially evident in the valleys of northern Utah. Air quality can be determined by the amount of particulate matter in the air, more specifically the size of the particles, which is measured in microns. A human hair is about 60 microns wide and fine sand is about 90 microns wide. Air quality is a public health concern because when inhaled, PM that is 10 microns wide or smaller can travel deep into the lungs and cause or aggravate heart and lung diseases. When PM

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in the air is higher, there is an increase in emergency groups are at greater risk of adverse health effects. room and doctor visits as well as absenteeism from school and work. UNHEALTHY (AQI 151-200): Everyone may begin to experience some adverse health effects, with sensitive Short term exposure to air pollution can cause coughing, shortness of breath, irritation of the eyes, and ir- groups at risk of more serious symptoms. regular heartbeat. Long term exposure can cause reduced lung function, respiratory illness, aggravation VERY UNHEALTHY (AQI 201-300): Triggers a health alert of existing heart disease, and even premature death signifying that everyone may experience more seriin people with existing lung diseases. Those with ous health effects. pre-existing lung and heart conditions, along with children and the elderly, are among those who are HAZARDOUS (AQI 300+): Triggers a health warning of most at risk for complications from poor air quality. emergency conditions affecting the entire population. Even exercising or working outdoors during times of In Washington County, there are 4 air monitoring stahigh PM conditions can increase your risk. tions run by various government agencies. We also An Air Quality Index (AQI) was created by the En- have a group called the Air Quality Task Force that is vironmental Protection Agency (EPA) to establish addressing air quality issues on a regular basis. This a national standard of how air quality is reported to task force consists of representatives from local industhe public. The five factors of the AQI are particulate try, municipalities, the Southwest Utah Public Health matter, sulfur dioxide, carbon monoxide, nitrogen di- Department, and Utah’s Department of Environmental oxide, and ozone. The AQI is based on a 1-500 scale Quality. Input from private citizens is also welcomed. and six risk categories indicating the quality of the The purpose of the task force is to get all stakeholders air: involved to find ways of maintaining good air quality in the region without vehicle emissions requirements GOOD (AQI 0-50): Satisfactory; little or no risk. or other federal oversight.

MODERATE (AQI 51-100): Acceptable, although respiratory symptoms may be experienced by sensitive groups of people (children, older adults, people with heart and lung disease).

We enjoy great air quality most days of the year in our part of the state. When high-risk days do occur, limit outdoor activities. Don’t use a wood burning stove if you have another heat source, combine driving trips, and avoid excessive vehicle idling. This will protect UNHEALTHY FOR SENSITIVE GROUPS (AQI 101-150): While your health as well as the health of your family and the general public may not be affected, sensitive community.

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IS YOUR CHILD UP TO DATE ON THEIR VACCINATIONS? CHECK WITH YOUR DOCTOR OR HEALTH DEPARTMENT (SEE PAGE 4). SWUHEALTH.ORG |Illustration PAGE 31 adapted from the Utah Department of Health.


There is healing in the trees for tired minds and for our overburdened spirits, there is strength in the hills, if only we will lift up our eyes. Remember that nature is your great restorer. -Calvin Coolidge

HEALTH MAGAZINE |SUMMER 2018

Utah Best of State 2017, 2018


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