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Introduction to Environmental Health /Environmental Medicine
Kory Groetsch & Brendan Boyle
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MDCH/ATSDR ServicesHealth Education
Human Health Risk AssessmentDocument that describes possible risks.Risk Health Outcomes
Tool:evaluate severity of the exposure and determinepublic health actionsExposure Investigation
Study of the population engaging in behaviors that resultin exposuree.g. Blood or urine samples, monitoring devices
Health Study Assess health outcomes level relative to measuredchemical exposures
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Overview
Overview of Environmental Medicine withinEnvironmental HealthCase StudiesProfessional Human ResourcesWeb Resources (CME )
State and Local Examples of EnvironmentalExposures
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Environment Key Elements
The places a person inhabits
Non occupationalIndoors and outdoors
Schools (children)Home and back yard
Recreational areasOccupational
OEM @ MSU: Ken Rosenman, MD(http://oem.msu.edu//index.asp )
Work environmentOverlaps with non-occupational
BehaviorsGardening, running, eating (fish, meat, etc.)
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EH Definitions (3 examples)Freedom from illness or injury related to exposure to toxicagents and other environmental conditions that arepotentially detrimental to human health.Public health that protects against the effects ofenvironmental hazards that can adversely affect health orthe ecological balances essential to human health andenvironmental quality.Environmental health comprises of those aspects ofhuman health, including quality of life, that are determinedby physical, chemical, biological, social, and psychosocialfactors in the environment. It also refers to the theory andpractice of assessing, correcting, controlling, andpreventing those factors in the environment that canpotentially affect adversely the health of present and futuregenerations.
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Environmental MedicineWork of clinicians
Definition: Study of effects upon human beingsof external physical, chemical, and biological
factors in the general environment.
Clinical EM: Evaluation, management, and study
of detectable human disease or adverse healthoutcomes from exposure to external physical,chemical, and biologic factors in the generalenvironment.
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Disciplines - EM
toxicologyepidemiologypublic health and preventionindustrial hygienepopulation medicine
research methods
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Clinical Approach EM
Characterizing ExposureChemicalSource
Link exposure to disease
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Patients - EM
Concern about a chemical exposure; nosymptoms but worried about futureeffects.
Symptomatic suspect environmentalcauseSymptomatic known chemical exposureSymptomatic no idea that something intheir environment is the cause
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Characterize Exposure - EMConfirm that exposure occurred
Medical History
Environmental Exposure History (I PREPARE)
Laboratory TestingCardinal Exposure Information
Identify the hazardous substances
Dose receivedDegree of contaminationDurationFrequency
Pathway of Exposure
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Routes of Exposure
INHALATION INGESTION
DERMAL CONTACT
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Environmental Media
Soil - ingestion, dermal, inhalation
Water - ingestion, dermal, inhalation
Air - inhalation
Sediment ingestion, dermal
Food (wild, local domestic, store purchased)
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Link Exposure to Disease - EM
Complicating FactorsLatency periodMultiple chemical exposures
PharmacokineticsLong duration in the bodyLack of unique disease presentation
Lack of science (minimal toxicological orepidemiological published literature)
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Link Exposure to Disease - EMGood exposure information (chemical, dose,
duration, frequency) exposure historyPossible effects/outcome information
Epidemiology literature human health outcomes
Animal toxicology studiesPlausible effectHistopathology or biochemical indicators
Clinical case reportScientifically limited (lack controls, small sample,bias)Clinically valuable information (tests andtreatments)
Local Clinical Experience
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Link Exposure to DiseaseEvaluate medical history for alternative etiology and preexisting illnessEvaluation of Chemical Test Results
What do the test results represent?E.g. Time frame, tissue, relationship to exposure
Was quality assurance conducted?What values would one used to interpret the chemical test results?
Is the comparison value appropriate for clinical use?Human health based value?How was the health based number calculated?
Calculation assumptionIs it in the same tissue as the test result?
Timing and severity of health effects consistent with dose-responseRemoval from exposure ends clinical symptoms; re-exposureexacerbates symptoms
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Diagnostic BenefitsEnd ongoing or prevent future exposures.
Assess future risk of disease from past exposures.
Help patient identify or eliminate possible causes.
MDCH/ATSDR Can arrange a presentation by an OEMMD about making an Environmental Medicine Diagnosis.
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Case Study 1 EventDevine et al. 2002. EHP . V10 (10). P.1051-55 Grand Rounds Case Study
November 1996, a gas leak and high CO levelsdetected by gas company, in a kitchen of arestaurant.45 yr old white female, who worked at therestaurant for 2 years, went to hospital 6 hr afterdetection of CO.Faulty furnace caused of CO, likely beenproducing CO for an extended period of time.Patient had been experiencing range of symptomsfor about 1 year leading up to this discovery
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Case Study 1 - Symptomsflu-like,
balance problems unable to walk straight, bumping intothings, several fallssevere headaches that persisted 24 hr/day, exhaustion,ear problems (right ear),
cloudy sensation,impaired reading, writing and speakingtingling or numbness in both thighs,
difficulty hearing,irritability,brittle teeth,pain in face.
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Case Study 1:Medical History - HighlightsCollege educated, full scholarship, best subjectwas in languages, IQ >130
Patient denied birth trauma, hypertension, headinjury, loss of consciousness, seizures, diabetes,thyroid, allergies, asthma, drug or alcohol use.
Patient was on vacation 5 days prior to the gas
leak and discovery of elevated CO levels.
Peak symptoms were in Jan April 1996.
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Case Study 1:Medical EvaluationsFirst (May 1996)
Diagnosed with sinus infection amoxicillinSymptoms became more severe, could not finishamoxicillin
Second - CO discovery (November 1996)6 hr after CO leakCarboxyhemoglobin not elevatedNo focal neurologic signs noted
Third - (February 26, 1998)Initial symptoms - 1 year prior to CO discoverySymptoms ended with CO discovery, except reading,writing, and speaking difficultiesNeurologist MRI, finding were normal
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Case Study 1:Medical Evaluations
Fourth Medical Evaluation (April 15, 1998)Neuropsychological testing
Below expectationsDemanding tasks (attention, learning, memory retrieval, mood)Short-term memory
Sensitivity to interference when completing memory tasks
Results suggestive of subtle frontal/subcortical lobedysfunction specifically in basal ganglia
Own clinical experience, typical of low level COexposure without loss of consciousness.
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Case Study 1:Medical Evaluations
Fifth Medical Evaluation (April 28, 1999)Neuropsychological testing
Similar below expectation resultsExecutive system dysfunction
Perseveration, pull to stimulus, poor development ofstrategies
Significant decrease in pyschomotor speedResults suggestive of subtle frontal/subcortical lobe dysfunctionspecifically in basal gangliaMRI Films
Conducted additional films with Fast Spin Echo MRI2 MRI experts (Neuroradiologist and Neuroscientist who doesneuroimaging research from VA Boston Health Care systems)Blind to the medical historyMultiple small lesions bilaterally in the basal ganglia
Most severe in globus pallidus, less in the putamen
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Case Study 1: LiteratureCO can cause all symptoms of the patient and thosesymptoms are non-specific.
Acute symptoms, recovery, days or weeks later haveneurologic/psychiatric symptoms
Progressive demyelination of white matter Markers of Exposure
Carboxyhemoglobin (HbCO) in bloodHalf-life 4-5 hr in ambient fresh air 45-80 min. at rest with 100% oxygenReflect [blood], not other [tissue]
CO in breathMRI
Lesions can be non-specific
NeurologicNeuropyschological (lack destinctive pattern)
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Case Study 1:Basis of Diagnosis
Environmental Exposure History
Known CO leak in her work environment that likely exist for anextend period of timeDenied history of prior similar health issuesHigh IQ and highly educated
SymptomsHeadaches and flu-like symptoms
Medical ExaminationLesions in the basal gangliaQuantified memory difficultiesExecutive system dysfuntion
Confirmed finding in scientific literature, case study
literature, and local clinical experience
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Case Study 2: Case HistoryPCC-Detroit, Consult of the Week, V. 1, No. 7 1/14/05
2 year old boy taken to Primary Care PhysicianDiagnosed with viral upper respiratory infectionand possible anemia (slightly pale)PCP ordered blood lead test and CBCBlood lead = 57 mcg/dl (CV:
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Case Study 2 :ED Physical Exam, Labs, X-rays
Physical exam: Normal except forpaleness of the conjunctiva and delayedspeech.
Lab: Repeat Pb = 64 mcg/dlX-ray:
paint chips in large and small intestine Abnormal bone remodeling and increasedCa deposits at several of the metaphyses.
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Case Study 2 : LiteratureSymptoms are not unique
Abdominal PainConstipation/DiarrheaDevelopmental Delays
Alterations in Mood
Health Effects Anemia
Damage hemoglobin formationKidney diseaseNerve damage
Developmental Delays
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16
10 g/dL20 g/dL
40 g/dL
50 g/dL
100 g/dLand over
Slight loss in IQ; hearing and growth problemsModerate loss in IQ; hyperactivity; poorattention span; difficulty learning; language
and speech problems; slower reflexesPoor bone and muscle development;clumsiness; lack of coordination; earlyanemia; decreased red blood cells;
tiredness; drowsinessStomach aches and cramps; anemia;destruction of red blood cells; brain damageSwelling of brain; seizures; coma; death
Case Study 2: Child Reactions to Lead Blood Lead Level Possible Health Effects
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Case Study 2: DiagnosisPica child who ingested lead based paintchips (x-ray of chips and elevated blood test)
Abnormal bone growth was attributable to thePb exposure
Anemia was most likely due to low Fe levels(Pb usually needs to exceed 100 mcg/dl tocause anemia)Delayed speech was not address in thediagnosis
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Case Study 2: PCC treatment of leadpoisoning of in asymptomatic children
Admit for BAL (injections) and CaNaEDTA (intravenousinfusion)
> 70
Admit for inpatient chelation with meso 2,3dimercaptosuccinic acid (DMSA) (oral) and CaNaEDTA(intravenous infusion)
40 69
retest lead level in 2 4 months, identify and abate source,education, nutrition counseling, medical evaluation by PCP
20 39
retest in 2 months, education, home inspection15 19
retest in 2-3 months, education10 14
Treatment[Pb](mcg/dl)
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Case Study 2. Treatment
Clear intestineglycol-electrolyte solutions (Golytely) vianasal gastric tube (NGT) with repeatedabdominal films every 8 12 hours.
Chelation
DMSA (oral)CaNaEDTA (intravenous infusion)
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Case Study 2 :Follow-up with Parents
Does the child exhibit pica behavior?How old is the home the child lives in?Does the child go to other homes for care? Howold?Do other young children come to you home?Might they be eating paint chips?Please describe your childs diet
Fatty foods cause paint chips to stay longer in the GItrackDiets low in Fe, Zn, Ca allows more Pb absorption.
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Groups of ChemicalsPesticides
home, farms, work, indoors and outdoors
Heavy Metals / Elemental
Volatile Organic ChemicalsShort-chain organicsIndoor Air Concerns (construction materials,
glues, cleaning products)Semi-Volatile Organic Chemicals
Long-chain organics
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Regular Issues at MDCH DEOE
Arsenic Asbestos Asthma Environmental TriggersCancer ClustersChemical Terrorism PreparednessClandestine Lab
Indoor Air mold, sewer gases, CO, natural gas leaks
Elemental mercury spillsLeadMiscellaneous chemical exposurePersistent Chemicals (dioxins, PCBs, chlordane, PBB, DDT,methylmercury)
Fish Consumption AdvisoryPesticides
Site-specific hazardous waste sites
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Regional Exposure PathwaysFrequent Fish Consumption local waters
Pine, Tittabawassee, Saginaw River and Bay residentspecies and benthic dwellersInland lakes top predator fish
Wild Game Consumption from Tittabawassee R.
flood plain (turkey meat and deer liver)Childhood lead exposure (homes older 1978)Carbon monoxide exposure
Gas generators, oil lamps, faulty furnaces
Elemental mercury spills
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Regional ATSDR Site WorkTittabawasse River Contamination
City of Midland ContaminationSaginaw River ContaminationVelsicol Chemical Plant Site (St. Louis, Mi)
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Overview of Velsicol PlantNIOSH documented exposures and effects 1977Source of state-wide PBB food contamination
Chlorinated chemical production (e.g. DDT)Do not eat fish from Pine River between Alma and MidlandPreviously, wild game advisories along Pine River (end 1995)Recent discoveries of past plant-site clean-up (Late 1990s to present)
Leaking of DNAPL into Pine River (DDT)
Highly elevated shallow ground water contamination off-site (not used fordrinking water)p-CBSA in the drinking water wells of the City of St. LouisOff-site soil contamination of multiple chemicals above background, somesamples exceed residential protection criteriaSoil gas issues (VOCs)
On-going investigations and clean-up both on and off the plant site Active locally-run Community Advisory Group and Technical Advisory Groupthat stay on top of the issues and conduct continuing education to the public.
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Human Resources Association of Occupational and Environmental
Clinics (AOEC) ( www.aoec.org )Lansing, East Lansing, Detroit, Royal Oak
Pediatric Environmental Health Specialty Units
(PEHSUs) ( www.aoec.org )Chicago
Poison Control Center ( www.mitoxic.org/pcc/ )
Health Care Professional ResoucesCollege of Medical Toxicologists
Toxicology and Response Section of MDCH
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Web ResourcesHazardous Substance Data Bank(http://toxnet.nlm.nih.gov/cgi-bin/sis/search )Environmental Health Perspectives ( http://www.ehponline.org/ )National Agricultural Pest Information System (NAPIS)(http://ppis.ceris.purdue.edu/htbin/epachem.com )
ATSDR ( http://www.atsdr.cdc.gov/ )Case Studies in Environmental MedicineToxFAQsToxicological Profiles
Medical Management GuidelinesToxGuides
MDCH-DEOE ( www.michigan.gov/mdch-toxic )MDCH Fact Sheet Matrix
(www.michigan.gov/documents/fact_sheet_matrix_12-21-05 148400 7.xls
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Continuing Education CreditsCo n t i n u i n g M e d i ca l Ed u c a t i o n ( CM E)
The Centers for Disease Control and Prevention (CDC) is accredited by theAccreditation Council for Continuing Medical Education (ACCME) to providecontinuing medical education for physicians. CDC designates thiseducational activity for a maximum of 2.0 hours in category 1 credittoward the American Medical Association (AMA) Physician's Recognition
Award. Each physician should claim only those hours of credit that he/sheactually spent in the educational activity.
Co n t i n u i n g N u r s i n g Ed u c a t i o n ( CN E) This activity for 2.3 contact hours is provided by CDC, which is accredited
as a provider of continuing education in nursing by the American NursesCredentialing Center 's Commission on Accreditation.
Co n t i n u i n g E d u c a t i o n U n i t s ( CEU ) Co n t i n u i n g H e a l t h Ed u c a t i o n S p e c i a l i s t ( CH ES)
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EXTRA SLIDES NOT USED
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Focal Neurological SignsFocal neurological signs help discriminate which
part of the nervous system is affected by a lesion. rontal lobe signs may include :Mental disturbance, e.g. dementia, apathy, inappropriate emotionEpilepsy
Grasp reflex, pout and snout reflexesUnilateral anosmia (Loss of the sense of smell. Also called olfactoryanesthesia .)
Parietal lobe signs may include :sensory disturbance, agraphia (A disorder marked by loss of the ability towrite.), acalculia (A form of aphasia characterized by the inability toperform mathematical calculations.
Temporal lobe signs may include :loss of long and short term memory
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