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Back to Basics, 2011 POPULATION HEALTH: Environmental

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Back to Basics, 2011 POPULATION HEALTH: Environmental & Occupational Health B. Pinard, MD (PGY4) G. Dunkley, MD Epidemiology & Community Medicine Based on s ... – PowerPoint PPT presentation

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Title: Back to Basics, 2011 POPULATION HEALTH: Environmental


1
Back to Basics, 2011 POPULATION HEALTH
Environmental Occupational Health
  • B. Pinard, MD (PGY4)
  • G. Dunkley, MD
  • Epidemiology Community Medicine
  • Based on slides prepared by Dr. R. Spasoff and
    Dr. N. Birkett

2
MCC Objectives Population health 78-6 Environment
  • Rationale
  • Environmental issues are important in medical
    practice because exposures may be causally linked
    to a patient's clinical presentation and the
    health of the exposed population. A physician is
    expected to work with regulatory agencies to help
    implement the necessary interventions to prevent
    future illness. Physician involvement is
    important in the promotion of global
    environmental health.
  • Terminal Objectives
  • Recognize the implications of environmental
    hazards at both the individual and population
    level.
  • Respond to the patients concerns through
    appropriate information gathering and treatment.
  • Work collaboratively with local, provincial and
    national agencies/governments as appropriate to
    address the concerns at a population level.
  • Make appropriate recommendations for patients and
    exposed populations so as to minimize their
    health risks and maximize their overall function.
  • Enabling objectives
  • Identify common environmental hazards and be able
    to classify them into the appropriate category of
    chemical, biological, physical and radiation.
  • Identify the common hazards that are found in
    air, water, soil and foods.
  • Describe the steps in an environmental risk
    assessment and be able to critically review a
    simple risk assessment for a community.
  • Conduct a focussed clinical assessment of exposed
    persons in order to determine the causal linkage
    between exposure and the clinical condition.
  • Be aware of local, regional, provincial and
    national regulatory agencies that can assist in
    the investigation of environmental concerns.
  • Describe simple interventions that will be
    effective in reducing environmental exposures and
    risk of disease (e.g. sunscreen for sunburns, bug
    spray for prevention of West Nile Virus
    infection).
  • Communicate simple environmental risk assessment
    information to both patients and the community.

3
78-6 ENVIRONMENT (1)
  • Objectives
  • - Identify common environmental hazards and be
    able to classify them into the appropriate
    category of chemical, biological, physical and
    radiation.
  • - Identify the common hazards that are found in
    air, water, soil and foods.

4
78-6 ENVIRONMENT (2)
  • Environmental exposure
  • Natural and human-made environment
  • Reservoirs air, water, soil, food
  • Route inhalation, ingestion, absorption
  • Exposure setting
  • Workplace occupational health (high level
    exposure, acute or chronic)
  • Outside workplace environmental health (low
    level exposure, chronic)

5
78-6 ENVIRONMENT (3)
  • AIR
  • Physical contaminants
  • Ionizing radiation Radon (lung cancer), UV (skin
    cancer)
  • Sound waves (hearing loss)
  • Chemical contaminants
  • Ozone at ground level (worsens asthma)
  • Carbon monoxide (asphyxiation)
  • Sulphur dioxide nitrogen oxides (exacerbation of
    breathing problems)
  • Organic compounds Benzene (carcinogen
    leukemia)
  • Second hand tobacco smoke (lung cancer)
  • Heavy metals industrial emissions (specific
    syndromes)

6
78-6 ENVIRONMENT (4)
  • AIR
  • Biological contaminants
  • Bacteria Legionella (pneumonia)
  • Dust mites (upper and lower-airway sx)
  • Pollen (upper and lower-airway sx)
  • Moulds (allergies)
  • Particulates (pollen, spores, aerosols) (asthma)
  • Global warming
  • Extreme weather (heat waves), change in
    distribution of vectors of disease, crop
    failures, etc.

7
78-6 ENVIRONMENT (5)
  • WATER
  • Biological agents
  • Bacteria E. coli, Salmonella, Pseudomonas
  • Protozoa (cysts) Giardia, Cryptosporidium (GI
    symtoms mainly)
  • Blue green algae (skin irritation, GI symptoms)
  • Higher risk aboriginal Canadians, rural
    population
  • Chemical agents
  • Volatile organic compounds (VOC), pesticides,
    heavy metals, other waste from industries
    (effects depend on contaminant)
  • Chlorination by-products - trihalomethanes (THM)
    (cancer)
  • SOIL
  • Chemical agents
  • Pesticides, petroleum hydrocarbons, solvents,
    motor oil , lead (effects depend on contaminant)
  • Higher risk infants/toddlers
  • Biological agents
  • Bacteria (tetanus)

8
78-6 ENVIRONMENT (6)
  • FOOD
  • Biological Contaminants
  • Salmonella- raw eggs, poultry, meat (GI sx)
  • Campylobacter - raw poultry and milk (GI sx,
    joint pain)
  • E. Coli - hamburger meat (diarrhea, HUS)
  • Listeria monocytogenes (listeriosis)
  • Clostridium botulinum (botulism)
  • Mould toxin (aflatoxin), BSE, virus, parasites
  • Chemical Contaminants
  • PCBs, dioxins/furans, pesticide residues (DDT),
    mercury
  • Food additives nitrites, sulfites (allergy)
  • Drugs given to livestock antibiotics, hormones

9
78-6 ENVIRONMENT (7)
  • Objective
  • Describe the steps in an environmental risk
    assessment and be able to critically review a
    simple risk assessment for a community.
  • Risk assessment
  • Process of evaluating the likelihood of
    occurrence and probable severity of health
    effects due to a hazard
  • Done by Occupational health agencies,
    Environmental protection agencies , Public health
    authorities, Clinicians

10
78-6 ENVIRONMENT (8)
  • Steps in risk assessment
  • 1. Hazard identification Is an environmental
    hazard involved? What is it?
  • 2. Risk characterization Is the hazard likely to
    cause these types of symptoms in this type of
    patient?
  • 3. Exposure assessment Is the patients exposure
    enough to cause these symptoms?
  • 4. Risk estimation How much has the hazard
    contributed to the patients condition?
  • Source Primer in Population Health

11
78-6 ENVIRONMENT (9)
  • Hazard Identification
  • Agent (based on clinical history see later on)
  • Adverse effect
  • Target population
  • Condition of exposure
  • Risk characterisation
  • Describe the potential health effects of hazard
  • Sources of info scientific literature,
    toxicology or poison center, public health
    department

12
78-6 ENVIRONMENT (10)
  • Workplace Hazardous Material Information System
    (WHMIS)
  • Labeling requirements for hazards
  • Indicates availability of Materials Safety Data
    Sheets (MSDS) more details on hazard, how to
    handle it, what to do if emergency
  • MSDS are available on the web should find one
    site and bookmark it (Health Canada
    http//www.hc-sc.gc.ca/ewh-semt/occup-travail/whmi
    s-simdut/index-eng.php)

13
78-6 ENVIRONMENT (11)
  • Exposure assessment
  • Characterize exposure of individual or population
  • Can be measured directly at times in people (ex
    blood lead level) or in environment
  • Estimated most of the time (from history or
    inspection of environment)
  • Consultants environmental medicine specialists,
    toxicologists, industrial/occupational hygienists
  • Risk estimation
  • Probability of being affected and severity of
    effect

14
78-6 ENVIRONMENT (12)
  • Objective
  • - Conduct a focussed clinical assessment of
    exposed persons in order to determine the causal
    linkage between exposure and the clinical
    condition.
  • Clues to environmental causes
  • Detailed environmental history

15
78-6 ENVIRONMENT (13)
  • Clues that illness is caused by environmental
    factors
  • Patient suspects it
  • Pattern of illness atypical (absence of usual
    risk factors, unusual age group, course of
    illness unusual, no response to tx)
  • Temporal pattern of illness (weekends/weekdays,
    holidays/home)
  • No obvious other cause
  • Signs/symptoms suggest specific toxins

16
78-6 ENVIRONMENT (14)
  • Environmental history - CH20PD2
  • Community neighborhood sources of hazard
    industry, waste storage
  • Home year of construction, renovations
    materials used in construction and decoration
    moulds garden and house plants use of cleaning
    products, pesticides, herbicides
  • Hobbies and leisure exposure to chemicals,
    dusts, or micro-organisms
  • Occupation current and previous occupations
    work with known hazards air quality
  • Personal habits hygiene products smoking
  • Diet sources of food and water cooking methods
    food fads
  • Drugs prescription, non-prescription, and
    alternative medications health practices

Source Primer in Population Health
17
78-6 ENVIRONMENT (15)
  • If a scanning question reveals a possible hazard,
    ask detailed questions to find out as much as
    possible about the nature and level of the hazard
    and then check Time, Place and Person
  • Time When did symptoms begin? When did exposure
    begin? When do symptoms get worse? When do they
    improve?
  • Place Where is the patient when symptoms get
    worse? Where is the likely hazard? What is the
    channel through which the hazard reaches the
    patient?
  • Person Does anyone else have similar symptoms?
    Who? When? Where?

Source Primer in Population Health
18
78-6 ENVIRONMENT (16)
  • Objective
  • Be aware of local, regional, provincial and
    national regulatory agencies that can assist in
    the investigation of environmental concerns
  • If evidence supports, or a strong suspicion
    exists for, a causal connection between exposure
    and the clinical presentation, notify the
    appropriate authorities to inspect the site and
    thereafter to decrease and eliminate exposure.

19
78-6 ENVIRONMENT (17)
  • Environmental Health Jurisdiction
  • Public Health Unit
  • Enforcement of water and food safety regulations,
    sanitation, local hazard assessment, reportable
    diseases
  • Municipal
  • Garbage disposal, recycling
  • Province/territory
  • Toxic waste disposal, air/water standards
  • Federal
  • Food regulations (Health Canada), designating and
    regulating toxic substances
  • International
  • Multilateral agreement (Kyoto Protocol)

20
78-6 ENVIRONMENT (18)
  • Objective
  • Describe simple interventions that will be
    effective in reducing environmental exposures and
    risk of disease.
  • Examples
  • Carbon monoxide CO home detector
  • Salmonella well cooked poultry and eggs, safe
    food handling
  • Listeria avoidance of unpasteurized cheese for
    pregnant women
  • West Nile Virus bug spray
  • UV light sunscreen, sunglasses, shade
  • Radon ventilation, air exchanger

21
78-6 ENVIRONMENT (19)
WHO, 2002, Global Solar UV Index
22
78-6 ENVIRONMENT (20)
  • Objective
  • Communicate simple environmental risk assessment
    information to both patients and the community.
  • Important to allow people to understand the risk
    and take action to avoid it
  • Elements of communication message, messenger
    (meaning), encoding, channel, decoding, recipient
    (understanding)

23
78-6 ENVIRONMENT (21)
  • Factors increasing perception of danger
  • Characteristics of exposure
  • Involuntary not under personal control
  • Unnatural unfamiliar
  • No trust in institution involved media attention
  • Characteristics of outcome
  • Catastrophic (not chronic) immediate
    irreversible
  • Unknown, uncertain outcome, dreaded outcome
  • Affect children or identifiable people
  • Source Primer in Population Health

24
74-4 WORK-RELATED HEALTH ISSUES
  • Key Objective
  • Determine whether the work place or environmental
    conditions are potentially hazardous, the impact
    on the health of the workers, and recommend
    preventive strategies.
  • Importance in Canada
  • 920 work place deaths in 2001
  • 373,216 lost-time injuries in 2001

25
Work-related Health Issues (2)
  • Selected Specific Objectives
  • Elicit history of occupation, list of current and
    longest held jobs, exposure to toxic/hazardous
    environments and identify potential relationship
    to patient presentation (temporal relationship to
    work or home activities)
  • - Counsel patients about safety issues and report
    findings to affected patients as well as
    employers (considering medical confidentiality
    issues)
  • Consider underlying medical conditions and work
    risk

26
Work-related Health Issues (3)
  • Categories of occupational hazards
  • Chemical organic solvents (carbon
    tetrachloride), mineral dusts (silica, asbestos),
    heavy metals, gases, second-hand smoke
  • Physical noise, temperature, air pressure,
    radiation
  • Biological bacteria, blood
  • Mechanical repetitive strain, trauma
  • Psychosocial stress

27
Work-related Health Issues (4)
  • Occupational health history
  • Work description and occupational profile
  • Prior and current exposure to hazards
  • Review of relevant workplace materials safety
    data sheets
  • Look for sx of disease job-related injuries
  • Temporal relationship between sx and exposure
  • Other environments, hobbies, occupation of family
    members (Toronto Notes, 2011)

28
Work-related Health Issues (5)
  • Under provincial jurisdiction except for 16
    federally regulated industries (e.g. banks,
    airports, highway transport) Canada Labour Code
  • 90 of workers are under provincial jurisdiction
  • Ontario Occupational Health and Safety Act
  • Defines rights of workers
  • participate, know, refuse and stop
  • Employers have duties to protect health and
    safety
  • Enforced by Ministry of Labour (inspectors)

29
Work-related Health Issues (6)
  • Ontario Workplace Safety and Insurance Act
  • Establishes WSIB to oversee work-site
    injuries/disease
  • Funded by employers only
  • Non-fault protection but no right to sue
  • MD must submit medical report to WSIB no need
    for patient waiver.
  • MD must report exposure to designated substances
  • Asbestos, arsenic, benzene, lead, mercury, vinyl
    chloride, etc.

30
Work-related Health Issues (7)
  • Occupational Health Program Essential
    responsibilities
  • Health evaluation of employees
  • Diagnosis/treatment of occup. injuries/illnesses
  • Emergency treatment of other injury/illness
  • Education of employees re occupational hazards
  • Evaluation of programs for the use of indicated
    personal protective devices
  • Assist management in providing a safe and
    healthful work environment. Inspect workplace.

31
Controlling Occupational Risks
Source
Path
Receiver
Potential approaches to risk control
Modify Redesign Substitute Relocate Enclose
Absorb Block Dilute Ventilate
Enclose Protect Relocate
32
Work-related Health Issues (9)
  • Work place safety issues can affect family
    members as well as the workers.
  • Asbestos
  • Causes asbestosis and lung cancer in miners and
    other workers
  • Asbestos in the air adheres to work clothing,
    even if the clothes are brushed
  • Cleaning of clothes at home liberates asbestos
    fibers and has been shown to cause cancer in
    family members.

33
Environmental and occupational health
  • Multiple Choice Questionsfor discussion

34
  • 1) Which one of the following is not a typical
    feature of asbestosis?
  • a) increased risk of cancer
  • b) pleural thickening and calcification
  • c) interstitial fibrosis
  • d) obstructive pattern on pulmonary function
    tests
  • e) none of the above

35
  • 2) The following statements regarding contact
    dermatitis are true EXCEPT
  • a) phototoxic dermatitis following topical
    application of creosote requires UV light
  • b) photoallergic contact dermatitis requires UV
    light to be manifested
  • c) contact eczema involves a type IV delayed
    hypersensitivity reaction
  • d) contact urticaria or hives is a common form of
    dermatitis
  • e) chemical burns by HCl and KOH may result in an
    irritant contact dermatitis

36
  • 3) The following statements regarding noise are
    true EXCEPT
  • a) temporary threshold shift recovers following
    cessation of noise exposure
  • b) permanent threshold shift is characterized by
    a progressive pattern of hearing loss
  • c) most cases of permanent threshold shift are
    surgically treatable
  • d) higher frequency noise is more damaging than
    low frequency noise
  • e) none of the above

37
  • 4) The frequencies most necessary for the
    understanding of speech extend from about
  • a) 20-20 000 Hz
  • b) 400-4 000 Hz
  • c) 250-8 000 Hz
  • d) 100-5 000 Hz
  • e) none of the above

38
  • 5) Lead exposure typically results in
  • a) chronic dermatitis
  • b) resting and intention tremor
  • c) extensor muscle weakness
  • d) arrhythmias
  • e) cerebellar ataxia

39
  • 6) Which of the following statements concerning
    the Workers Compensation Act is true?
  • a) the worker reserves the right to sue the
    employer for negligence
  • b) funding is provided by the provincial
    government
  • c) the worker is guaranteed payment from the
    first day of injury/illness if it is deemed to be
    work-related
  • d) the Workers Compensation Board is an
    independent, private agency
  • e) none of the above

40
  • 7) Which of following statements regarding
    radiation is false?
  • a) natural background radiation accounts for
    about half of a typical persons exposure
  • b) ionizing radiation causes intestinal villi to
    become denuded
  • c) exposure to non-ionizing radiation may result
    in cataracts
  • d) ionizing radiation results in an increased
    incidence of neoplasia such as lung and thyroid
  • e) none of the above

41
  • 8) Which statement concerning vibration induced
    white finger disease is false?
  • a) early symptoms include tingling and numbness
    of the fingers when at rest
  • b) swelling of the fingers over knuckles may be
    an early feature
  • c) cold, damp conditions may precipitate symptoms
  • d) the affected area eventually spreads to
    involve all fingers
  • e) none of the above

42
  • 36) All of the following statements concerning
    occupational health are true EXCEPT
  • a) disorders of reproduction are among the top 10
    work-related diseases and injuries
  • b) most workers are covered by both federal and
    provincial legislation with respect to workplace
    health and safety
  • c) skin problems and hearing problems together
    are responsible for half of WCB claims
  • d) a complete occupational medical history
    includes investigation of the temporal
    relationship between symptoms and exposure

43
  • 37) Which of the following statements concerning
    exposure to solvents in the workplace is true?
  • a) each solvent compound has a specific antidote
    that can be used to treat exposure
  • b) a prominent symptom of solvent exposure is
    memory loss
  • c) some solvents can cause skin dryness and loss
    of subcutaneous adipose tissue
  • d) solvents do not affect the bone marrow
  • e) all of the above

44
  • 39) All of the following statements about
    environmental health are true EXCEPT
  • a) levels of toxic agents measured in the
    environment may not reflect internal organ levels
  • b) the federal government monitors the quality
    and types of industrial emissions and toxic waste
    disposal
  • c) sick building syndrome is associated with
    Pontiac fever and Legionnaires disease
  • d) all humans have detectable levels of PCBs
  • e) none of the above is true

45
More MCQs
  • Here are some more questions that students can
    use to test their own knowledge
  • http//www.medicine.uottawa.ca/sim/data/Self-test_
    Qs_Environmental_e.htm
  • (The questions contain comments on the answers,
    to illustrate why a given response is not correct)
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