Implementing Interventions for Heat-related Illness and Wildfire Smoke Exposure in North Carolina

Whitney Reynier
Posted on: 6/25/2019 - Updated on: 6/22/2023

Posted by

Rachel Gregg

Project Summary

The North Carolina Department of Health and Human Services (NCDHHS) is utilizing the Building Resilience Against Climate Effects (BRACE) framework to address heat-related illness and wildfire smoke exposure in their most vulnerable counties. NCDHHS has collaborated with community stakeholders to develop tailored health intervention activities, and is implementing two adaptation pilot projects at the local level. One project is piloting a heat alert system and associated heat education efforts to ameliorate incidents of heat-related illness. A second project is integrating wildfire smoke exposure and safety messaging into existing Smokey Bear education programs for elementary students. Lessons learned from these two pilot projects will be used to refine health and climate messaging and develop additional adaptation projects in the future.


NCDHHS initially began working on climate change issues due to concerns about potential public health impacts from increasing temperatures. With funding from the Centers for Disease Control and Prevention (CDC), the department implemented the BRACE framework, completing an impacts assessment that evaluated all potential climate threats to public health. Published in 2015, this Climate and Health Profile identified heat-related illnesses associated with extreme heat events and wildfire smoke exposure as the greatest climate impacts of concern in North Carolina. Other identified impacts included air pollution, extreme weather events, and water-borne pathogens.

With additional CDC funding, NCDHHS then conducted more in-depth vulnerability assessments for heat-related illnesses and wildfire smoke exposure to identify priority adaptation locations. Using the state syndromic surveillance system, the department tracked heat-related emergency room (ER) visits, which revealed high ER visit rates in the southeast Sandhills region of the state. Subsequent analyses identified a five county sub-region as being highly vulnerable to heat-related illness. For wildfire smoke, NCDHHS investigated the number of pre-existing conditions that could be aggravated by smoke exposure, and used GIS mapping to identify the most vulnerable counties in the state (e.g., those with high exposure to wildfire smoke and high numbers of residents with underlying conditions). One county was ultimately prioritized for action because in addition to high vulnerability, residents also had low access to tools that could inform healthy decision-making, such as the EPA’s air quality information system.


NCDHHS is now working on implementing two local health adaptation pilot projects to address heat and wildfire. The department is piloting a heat health alert system in southeast North Carolina. This system will alert target populations when heat levels become dangerous, and provide residents with actions they can take to reduce their risk. The heat health alert system is tailored to residents most at risk for heat-related illness, including farm workers, older adults, low-income families, and youth. For wildfire smoke exposure, NCDHHS is collaborating with the U.S. Forest Service in North Carolina to integrate smoke safety information with existing Smokey Bear programs for elementary school students. Educational pieces include identifying smoke-sensitive health conditions and messaging around healthy behaviors during smoky conditions. For both projects, NCDHHS has developed full implementation and monitoring plans (e.g., heat and wildfire smoke).

These intervention actions were selected after a thorough review process with stakeholder input. NCDHHS first identified a range of possible intervention actions vetted in the scientific literature. These options were presented to and evaluated by stakeholders according to a variety of criteria, such as ease of implementation, cost, and timeliness. Stakeholders also added additional criteria, such as language accessibility. Stakeholders ultimately selected health intervention actions based on a combination of evaluation scores and the needs of local communities. For example, for the heat health alert system, stakeholders emphasized the need to include a health education component to teach residents how to use the system. For wildfire smoke, the chosen intervention activity was entirely stakeholder-designed rather than sourced from the literature, as stakeholders strongly believed leveraging existing Smokey Bear programming would be the best approach.

In addition to identifying appropriate and feasible health interventions at the local level, community stakeholders have also been critically important in refining messaging to best reach residents. These stakeholders include local health departments and emergency management departments, non-profit organizations, agricultural extensions, and land management agencies (e.g., local fire departments, the U.S. Forest Service, The Nature Conservancy).

Outcomes and Conclusions

NCDHHS has CDC funding through 2021. They plan to continue implementing these two pilot projects, and then revise and expand their adaptation activities based on lessons learned. For example, they are currently collecting feedback on the utility of different heat health education materials and trainings. They are also tracking over the longer-term whether the implemented health interventions alter health behaviors and outcomes. All feedback will be used to update existing implementation and monitoring plans, and to refine and develop additional educational materials.

Primary barriers encountered by NCDHHS during the course of their work include working in rural communities and communities with diverse health problems. Most existing adaptation materials are geared toward larger population centers. Rural communities face different challenges (e.g., low population numbers and population density, high poverty rates, low rates of higher education), and adaptation options developed for urban areas are not always applicable. For example, rural residents may not be able to easily travel to cooling shelters during extreme heat events. Additionally, many of North Carolina’s most vulnerable communities face diverse health impacts and have very limited resources. For example, many of the communities the NCDHHS is working with also experience high levels of poverty, score poorly in many health categories, and were those hardest hit by Hurricanes Matthew and Florence.

NCDHHS has found that relying on the expertise and connectedness of community leaders is key in addressing these challenges. Although vulnerable, these communities have survived and been resilient to past extreme events and associated health impacts. Community leaders have detailed knowledge about their community and how best to respond to climate challenges moving forward. NCDHHS has found that as a state agency, they experience the most success by empowering local community leaders to use and adapt the BRACE framework, and by building on existing community efforts (e.g., Smokey Bear education programs).


Reynier W. 2019. Implementing interventions for heat-related illness and wildfire smoke exposure in North Carolina [Case study on a project of the North Carolina Department of Health and Human Services]. Product of EcoAdapt's State of Adaptation Program. Retrieved from CAKE: (Last updated June 2019)

Project Leads

Lauren Thie

Project Contact

Lauren Thie, [email protected]

Affiliated Organizations

In collaboration with our partners, DHHS provides essential services to improve the health, safety and well-being of all North Carolinians.