aetna presentation environmental health

Environmental Health: Children in minority communities

David JonesEnvironmental Health and Safety

Duval County Health Department

What is Environmental Medicine?

Environmental Medicine focuses on the person and the environment. Emphasizes:

Identification Diagnosis Treatment Prevention

Environmental Medicine

There are four types of environmental mediaAirWaterSoilFood

The Media of Environmental Hazards

Air, water and food are the major environmental media or vectors through which exposure to hazardous environmental agents occur.Disease Vectors - mosquitoes, rats, birdsAdditionally, fire in the form of incineration has emerged as a major and somewhat controversial issue in environmental medicine.

The Media of Environmental Hazards

While soil is often overlooked as a route of exposure, in some cases such an oversight may result in a critical underestimate of actual exposure.Home gardens may be an exposure route dermal or through inhalation to contaminants in soil, dust, or chemical update in the plants.

The Discipline of Environmental MedicineA broad discipline involving:

Understanding the impact of the environment on human health

Eliciting appropriate exposure historyRecognizing exposure-related diseasesIdentifying and Accessing resourcesDiscuss environmental risks to patientsTreating Patients

How do chemicals enter the environment?

There are six ways in which hazardous substances can enter the environment.

Direct exposure (pesticides, cigarettes, lead in paint)

Direct discharge (toxic emissions from transportation, smokestacks, incinerators)

Inadequate landfills (runoff or leaching of contaminants into drinking water and food chain)

How do chemicals enter the environment?

Illegal Dumping (dumping of oil in backyards, or mass dumping of toxic chemicals)Catastrophic events (accidental releases of large quantities of extremely virulent toxins)Ecological catastrophic events (events that lead to human health consequences such as volcanoes, floods, famine and hurricanes)

Environmental hazards cont…The major environmental hazards and their relative importance in various environmental settings.

Chemical agents: pesticides, VOC’S, and PCB’S

Physical agents: ionizing and nonionizing radiation, vibration, temperature, and noise.

Biological agents: infectious and allergic disorders

Interaction between hazardous exposures and humans

Four characteristics critical to exposure assessment:

Route ( Inhalation, Ingestion, Dermal)Magnitude (Concentration or Dose)Duration ( Minutes, Hours, Days, Lifetime)Frequency (Daily, Weekly, Monthly,

Seasonally)

Interaction between hazardous exposures and humans cont…

All of the environmental media are possible exposure routes, and should be considered in a risk assessment.Humans have access to environmental toxicants by contaminated food, drinking contaminated water, and breathing contaminated air. Hazardous pollutants may also enter the human body through the skin or a combination of these routes,rarely are humans exposed to a single pollutant along a single route.

Relationship of magnitude, duration, and frequency

The concept of “dose” in environmental medicine is a function of the amount of the toxicant absorbed and time factors.A toxicant may be present in very low, perhaps minute concentrations,and stimulate biological responses in the host.Even a very small concentration of a highly toxic substance can cause a significant clinical response.

Soil Ingestion

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Environmental Medicine and Human Health

Environmental medicine plays two major roles in human health.

Provides the diagnosis and treatment of health complaints attributable to the environment.

Contributes to a much broader understanding of the unity of human health and environmental quality.

Recognition of Human Hazardous Exposures

The only way to accurately determine to what extent persons come in contact with a specific environmental hazardous pollutant is to actually measure the exposure.There are three ways to accomplish this:

Use of micro-environmental samplersUse of personal monitorsUse of biologic measurements in human

tissue

Chronology of Children's Environmental Health

1776 - Young Chimney Sweeps, Cancers Linked to Environmental Toxicants.• London physician Percival Pott notes

incidence of scrotal cancer in young chimney sweeps.

1904 - Paint Linked to Lead Poisoning in Children.• J.L. Gibson of Queensland, Australia, is the

first to recognize paint as the source of lead poisoning.

Chronology of Children's Environmental Health

1970 - Clean Air Act Enacted.• President Nixon establishes the US

Environmental Protection Agency and Congress adopts the Clean Air Act.

Sept 1990 - Pediatric Environmental Health Curriculum Developed.• Kids and the Environment Project develops the

first curriculum on environmental health hazards for children.

Chronology of Children's Environmental Health

Feb 1994 - President Issues Executive Order on Environmental Justice.• The Executive Order requires all federal

agencies to make achieving environmental justice part of their missions.

May 1996 - Pediatric Faculty Trained in Children's Environmental Health.• The first training of pediatric faculty at the

Ambulatory Pediatric Association Annual Meeting takes place.

Chronology of Children's Environmental Health

Jan 1997 - Training of Pediatricians To Include Environmental Health.• The Pediatric Residency Review Committee

requires the inclusion of pediatric environmental health training for pediatric residents.

Children's Environmental HealthEnvironmental health is an ongoing concern within the pediatric clinical practice.Children live in a very different environment today than previous generations.Advancements in information technology have contributed to the discovery and use of thousands of new chemicals.Unlike our pharmaceutical drugs, many of the 70,000 chemicals used in the U.S. have not been tested for safety when exposed to humans.

Children's Environmental HealthDeveloping Organ Systems

Environmental toxicants can cause permanent damage to developing nervous, immune, and respiratory systems.

Biological SensitivityChildren’s skin, respiratory and

gastrointestinal absorption is greater than adults.

Children's Environmental Health

BehaviorHand-to-mouth activity and crawling can

increased probability of exposure to toxicants.Diet

Children eat more pound for pound than adults. So they will absorb more hazardous residues in food.

Children's Environmental HealthThe health care provider should serve as an:Investigator

Frontline investigator of environmental related illnesses within the clinical society and community.

EducatorCredible source of information to patients,

their families and communities.Information by provider can inform individuals

and communities how to reduce or eliminate toxic exposure.

Children's Environmental Health

AdvocatePrevention is the key to protection!Policy development at Local, State, and

Federal levels.

Children's Environmental Health Children are more vulnerable than adults to exposures.“A little kid goes from a single cell to a laughing, sociable, intelligent, friendly human being over a course of two years - that’s dramatic growth!”They are in a dynamic state of growth, with cells multiplying and organ systems developing at a rapid rate. In the first four months of life an infant more than doubles its weight.

Children's Environmental HealthIn its first environment, its mother's womb, the fetus may be permanently damaged by exposure to a wide variety of chemicals that can cross into its bloodstream through the placenta.These chemicals include:

LeadPolychlorinated BiphenylsMethylmercuryEthanol and Nicotine from environmental

tobacco smoke

Environmental Justice

All children are affected by environmental hazards. Pollution and environmental degradation recognize no county, state, regional, or national border.Children living in poverty and children in racial or ethnic communities are at disproportionate risk for exposure to environmental hazards.

Environmental Justice

Poverty can compound the adverse effects of exposure to toxicants such as:

Inadequate HousingPoor NutritionLimited access to health care

Environmental Justice

Sixteen percent of White-Americans or Non-Hispanic children live in poverty.The rates in the African-American and Hispanic communities are 42% respectively.

Known Hazards for Children

RadiationSolventsAsbestosMercuryArsenicSulfur DioxidePM2.5

NitratesMolds/MildewBacteriaParasitesOzonePetroleum by-products

Environmental Medicine

Various diseases encountered in environmental medicine are:

Contact Dermatitis Obstructive Lung Disease Nephritis Neuropathy Various Cancers Gastrointestinal

Outcomes from Environmental Hazards

EffectsCarcinogenicityHeritable genetic & chromosomal mutationDevelopmental ReproductiveNeurotoxicity

CulpritsBenzene, PAH’SIonizing radiationLead, MethylmercuryBenzo[a]pyreneOrganophosphate

Known Hazards for Children

They fall into categories such as:NeurotoxinsEndocrine DisruptorsCarcinogensRespiratory Irritants and Inflammatants.

Known Hazards for Children

The following are three selected environmental hazards known to seriously impact children's health.

LeadAir PollutionPesticides

Lead

Exposure to lead has been associated with an array of neurodevelopmental effects including:

Attention DeficitsDecreased IQ scoresHyperactivity and Juvenile Delinquency

Lead-based paint in older homes is still the most common source of high-dose lead exposure for preschool-aged children.

Lead

Childhood lead exposures can occur through:Ingestion of paint chipsDust from deteriorating surfacesChewing on painted cribs, or through

inhalation of lead paint dust.

Air Pollution

Air pollution affects children more than adults because of their narrow airways, rapid rate of respiration and the fact that they inhale more pollutants per pound of body weight.Common indoor air pollutants include:

Carbon MonoxideRadonEnvironmental Tobacco SmokeAsbestosFormaldehyde and Mercury

Asthma African Americans < 24 are 3X - 4 X more likely to be hospitalized for asthma as white children.Children of Hispanic mothers have an asthma rate 2.5X whites and 1.5X of African Americans.

Puerto Ricans-11.2% Cuban Americans-5.2% Mexican Americans-2.7%

Non-Hispanic blacks-2.9% non-Hispanic whites-3.3%Much of disparity is thought to be due to poverty not race.

PesticidesChildren are often exposed to toxicants through the agricultural and home use of pesticides or the ingestion of pesticide residues on food or in water.Pesticides used today generally fit into five main categories:

InsecticidesHerbicidesFungicidesNematocides Rodenticides

Number of Calls to Poison Control Centers About Pediatric Pesticide Poisonings,1999*

Childhood Diseases

Researchers are working hard to determine whether an increase in childhood diseases is linked to environmental exposures.Childhood asthma has increased by more than 40% since 1980, affecting more than 4.2 million children under the age of 18 nationwide.Childhood cancers have risen significantly over the past 15 years: Acute Lymphocytic Leukemia is up 10% and brain tumors are up more than 30%.

Future ConcernsResearch that identifies patterns of environmental diseases in children.The developmental process, including the critical periods of vulnerability during which environmental exposures can cause adverse health effects.The health effects of low level exposures to environmental toxicants such as dioxins, endocrine disruptors and lead. The health effects of cumulative and multiple exposures to environmental hazards.

Policy Implications

THE KEY TO PROTECTION IS PREVENTION.There has been a dramatic shift in the recognition of children's environmental health issues in Congress and Federal Agencies.

ConclusionEnvironmental medicine is the clinical arm of environmental health. Involves diagnosis and prevention of illness caused or influenced by external agents in a persons environment.Once an environmental disease has occurred, it’s treatment is often within the domain of internal medicine, but it’s recognition and prevention is the essence of the environmental health practice.Once a hazard has been recognized, control, and reduction of exposure should follow swiftly.

Conclusion cont..

Since it’s establishment in 1975 environmental medicine has become a vital tool in the prevention and diagnosis of many environmental related illnesses.Environmental medicine will play an even greater role in the lives of everyone as we continue to educate the public as well as public policy makers on environmental related issues.

References & Resources

American Academy of Pediatrics, Handbook of Pediatric Environmental HealthATSDR Case Studies in Environmental MedicineU.S. Department of Health and Human Services, Public Health Services Washington, D.C.Environmental Health Perspectives Volume 110, Number 8, August 2002

References & Resources

The Institute of Medicine (IOM) 1995 reportEnvironmental Medicine: Investigating a Missing Element into Medical Education, Nursing, Health, and the Environment.Pediatric Environmental Health Units. Environmental Medicine Brooks, Stuart, Gochfeld, Michael, Herzstein, Jessica, Jackson, Richard