The role of Pediatric Environmental Health Specialty Units (PEHSU): Collaboration and Expertise Jennifer Lowry, MD Director, Mid-America Pediatric Environmental.

The role of Pediatric Environmental Health Specialty Units (PEHSU):

Collaboration and Expertise

Jennifer Lowry, MDDirector, Mid-America Pediatric Environmental Health

Specialty UnitChildren’s Mercy Hospital

Kansas City, MO

Disclaimer• This presentation was prepared by the Association of

Occupational and Environmental Clinics (AOEC) and funded (in part) by the cooperative agreement award number 1U61TS000118-05 from the Agency for Toxic Substances and Disease Registry (ATSDR).

• Acknowledgement: The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing funds to ATSDR under Inter-Agency Agreement number DW-75-92301301-0. Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.

Mission• Improve the environmental health of

children by:• Enhancing educational and consultative

services to clinicians, health professionals and the community.

• Providing evidence-based information from a network of experts in environmental health.

PEHSU History• 1996 ATSDR Child Health Initiative - emphasis on

environmental hazards to children’s health.• The first PEHSU programs were established in

1998 in Seattle and Boston following two, large environmental exposure incidents: – 1995 to 1996 mercury exposure factory converted to

apartments in New Jersey. 1– 1996 to1998 methyl parathion exposure potentially

affecting 400+ children in Illinois, Mississippi and Ohio.

What is a PEHSU?• A PEHSU site is a collaboration between an

Association of Occupational and Environmental Clinic (AOEC) member clinic and an academic pediatric program.

• A typical PEHSU staff includes a project director, a coordinator, an occupational environmental medicine physician, a pediatrician, and often other specialists such as a toxicologist or industrial hygienist.

PEHSU Services• Consultation for clinicians/health

professionals regarding children’s environmental health concerns.

• Education/Outreach on pediatric environmental health provided to clinicians/health professionals, clinical trainees and the general public.

• Referral to appropriate resources for children with environmental health needs.

Funding and Management of• Agency for Toxic

Substances and Disease Registry (ATSDR)

• U.S. Environmental Protection Agency (EPA)

• Association of Occupational & Environmental Clinics (AOEC)

PEHSU Site Locationswww.pehsu.net (or 1-888-347-2632)

• Region 1: Boston, MA• Region 2: New York, NY• Region 3: Washington, DC• Region 4: Atlanta, GA• Region 5: Chicago, IL

and Cincinnati, OH (satellite location)• Region 6: Tyler, TX

• Region 7: Kansas City, MO

• Region 8: Denver, CO• Region 9: Irvine and San Francisco, CA• Region 10: Seattle, WA• Alberta, Canada• Guadalajara, Mexico

Boston Children’s Hospital Boston

Cambridge Hospital

New York CityMount Sinai

Medical Center

Washington DCChildren’s National

Medical Center

AtlantaChildren’s Healthcare of Atlanta

Egleston Children’s HospitalHughes Spalding Children’s Hospital

TylerUniversity of Texas

Health Science Center

EdmontonMisericordia

Community Hospital

Kansas CityChildren’s Mercy

Hospitals and Clinics

San FranciscoUniversity of

California Hospital

SeattleHarborview Medical Center

University of Washington Medical Center Children’s Hospital and Regional Medical Center

DenverNational Jewish Medical

and Research CenterDenver Health and Hospitals

Chicago Stroger Hospital of Cook County

IrvineIrvine Medical

Center

GuadalajaraUniversity of Guadalajara Health Sciences Center

Pediatric Environmental Health Specialty Units (PEHSU) In North America - Hospital Affiliations

Canada

Mexico

Alaska

Hawaii

VirginIslands

PuertoRico

PEHSU 2012 Annual Report, October 2013

PEHSU 2012 Annual Report, October 2013

PEHSU 2012 Annual Report, October 2013

PEHSU 2012 Annual Report, October 2013

Website: www.pehsu.net

PEHSU Factsheets

What is Pediatric Environmental Health?

Pediatric Environmental Health

A discipline that involves the identification, treatment, prevention and control of environmental exposures and associated adverse health effects in infants, children, adolescents, and young adults

http://www.aap.org/healthtopics/environmentalhealth.cfm

Cumulative riskPoverty

Lead

Allergens

Poor nutrition

Stressed mother

Noise

Squalid neighborhood

No parks

From Lecture of Dr. Howard Frumkin

Variations in Susceptibility with Developmental Stages

• Preconception• Fetus• Newborns• Infants

• Toddlers (1-2 yrs)• Young Child (2-6)• School Aged (6-12 )• Adolescents (12-18)

Disparities in Environmental Exposures

Hood, E. (2005). "Dwelling disparities: how poor housing leads to poor health." Environ Health Perspect 113(5): A310-7

21

Lead

SOURCE: Meyer PA, et al. Surveillance for elevated blood lead levels among children--United States, 1997-2001. MMWR 2003;52(SS10):1-21.

22

Air quality

0

10

20

30

40

50

60

70

80

1 2 3 4

Number of air quality standardsexceeded

Pe

rce

nt

po

pu

lati

on

Whites

Blacks

Hispanics

Source: Wernette DR, Nieves LA. Breathing polluted air: minorities are disproportionately exposed. EPA Journal 1992;18:16-17

23

Asthma and Equity• Asthma prevalence twice as high, and

mortality three times as high, in blacks as in whites

• Asthma prevalence 3x higher in Hispanic than non-Hispanic children

• Asthma hospitalization among Medicaid children: 93% in blacks, 34% in Hispanics, compared to whites

Extent of knowledge

Grandjean P and Landrigan PJ, Lancet. 2006

• More than 80,000 chemicals registered with EPA

• Greatest risk are 2,863 high-production-volume (HPV) chemicals (produced in amounts of 1 million pounds or more per year) • Fewer than half have been

tested for Toxicity to Human Health

• Less than 10% have been tested for pediatric neurotoxicity

• Gaps in knowledge are particularly great in regard to developmental toxicity

25

Effect of Removing Lead From GasolineBlood Lead Levels in US

Lead Poisoning• No level of lead in the blood is safe. • In December 2012, the United States Centers for

Disease Control and Prevention (CDC) established a new “reference value” for blood lead levels (5 mcg/dL), thereby lowering the level at which evaluation and intervention are recommended

• In 2013, the CDC also defunded childhood lead poisoning prevention programs across the US resulting in the inability for state and local health departments to respond to the increasing numbers of lead poisoned children.

Lead Poisoning• Health care professional as advocate• Environmental education in US medical

schools is limited despite agreement that increased emphasis is needed.

• Past reliance on health departments has resulted in decreased awareness of environmental exposures and their management.

Case• A health care professional (HCP) notified the regional PEHSU

regarding a child with a BLL of 25 mcg/dL. • Officials at the local and state health department had

mentioned that nothing could be done due to lack of resources given the recent loss of funding from the CDC. 

• Regional PEHSU determined that the child’s exposure was a result of the father’s work in print shop that used lead ink.

• The father’s screening BLL was above 100 mcg/dL revealing the extent of exposure to the child.

• Officials with the Occupational Safety and Health Administration (OSHA) became involved to assess other shop workers and their children. Testing of other employees and their families is ongoing

Study Aims and Methods• Aim: To investigate trends in US PESHU lead

contacts• Methods:

– A retrospective study of PEHSU contacts between 1/1/2007 and 12/31/2012

– Seasonal and regional trends in lead contacts were analyzed along with patterns in location of lead exposure, route of exposure, patient geographic location, referral source, patient age and gender. 

Results• Lead was overwhelmingly the primary topic of concern

(between 27-35% annually)• More than 78.5% of calls or referrals to PEHSU’s were

from health care professionals. – The majority of calls from HCP regarded children aged 2-5

years. – The majority of exposures (70%) occurred in the home setting.

This included work exposures being brought home to children.

• Outreach activities were primarily focused on established health care professional training rather than student/trainee education. 

Age of PatientAges Percentage of total calls

Prenatal 0.71%

0 - 11 months 8%

12 - 23 months 26.2%

2 – 5 years 45.7%

6 – 9 years 7.5%

10 - 13 years 3%

14 – 18 years 2.6%

19 years 0.4%

Adult 0.6%

Unknown age 4.1%

ResultsExposure Setting Percentage of Total

Home 79.5%

Work/School/Public Area/Daycare 1.05%

Unknown 19.4%

Caller information Percentage of Total

Health Care Professional 40.7%

Parents/Grandparents 55.2%

Parents referred by HCP to call 67% of the 55%

Limitations• Retrospective review of data• Incomplete data as reliance on data

entry• Underrepresentation of exposures as

dependent on calls to PEHSU

Conclusions• Lead remains a serious threat to children in the

US and worldwide• Medical and public health communities continue

to have questions regarding environmental exposures in children.

• The majority of environmental calls to PEHSUs are regarding home exposures

• With lack of public health funding, PEHSUs may be relied upon for this information.

Questions?