Risks and Resources for Kansas Schools

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Risks and Resources for Kansas Schools

• Jennifer Lowry, MD
• Director, Mid-America Pediatric
• Environmental Health Specialty Unit
• EPA Region 7

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Special Considerations for Children

• Physical Environment
• physical location, breathing zones, oxygen
  consumption, nutrition, development
• Biological Environment
• absorption, distribution, metabolism, target
  organ susceptibility
• Social Environment
• regulations and laws

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Environmental Hazards in Schools

• Any risk factor that can cause acute or chronic
  illness or injury to a schools students, faculty
  or staff
• Can be described from a number of perspectives
• physical
• chemical
• infectious
• psychological
• natural

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Environmental Hazards in Schools

• Traditionally, schools have limited focus to
  preparation and drills for fires, natural
  disasters, climactic control and generic accident
  prevention.
• More recently, other risks identified such as air
  pollution, radon gas, asbestos and lead.
• Others include benzene, explosives, radioactive
  materials, aromatic hydrocarbons, colchicine,
  ethidium bromidechromium, cadmium, mercury,
  silver, arsenic, and barium (all of which can be
  found in chemistry labs in schools)

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Structural Conditions of Schools

• 1995 study by US General Accounting Office found
  nations schools to be in structural disarray
• Third of schools needed extensive repair or
  replacement
• Of remaining two-thirds, 60 needed at least one
  component repaired, overhauled or replaced
• Common problems were damaged framing, floors, and
  foundations defective heating, cooling and
  ventilation systems and leaking roofs
• Approximately 14 million children attended these
  substandard schools

US General Accounting Office School Facilities
Condition of Americas Schools. Publication
GAO/HEHS-95-6. Washington, DC, GAO, 1995
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Convenience Sample Survey of Schools

• 1999 survey of 39 New York City public schools
• Hazardous conditions including inadequate heat or
  lack of fire extinguishers in 30
• Unclean bathrooms in 45
• 1998 survey by California Department of Health
  Services
• 78 contained lead-based paint
• 38 had flaking or pealing lead-based paint
• 18 had water-lead levels that exceeded US EPA
  drinking water standards

Cummins SK and Jackson RJ. The Built Environment
and Childrens Health Pediatric Clinics of North
America. 2001 48 1241-56
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Chemicals in Schools

• Every year, hundreds of thousands of dollars are
  spent on school incidents involving chemicals
• dangerous chemicals which may have been in
  schools for decades
• result in illness and injury and loss of valuable
  education time
• The public school system, primarily high schools,
  may generate chemical wastes from their science
  laboratories and art classrooms.

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Chemicals in Schools

• EPA
• Schools Chemical Cleanout Campaign
• 69,000 pounds of hazardous chemicals removed from
  secondary schools (1999-2003)
• 22,000 pounds removed in 2004
• Few funds available but work with existing state
  programs

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Chemicals in Kansas Schools

• KDHE and Kansas School Lab Sweep Program
• Served secondary schools in 91 of Kansas 105
  counties
• 194 schools
• 11,500 containers (14,900 pounds) of hazardous
  waste
• Provides chemical assessment and disposal service
  to school that signs good faith agreement
• Scheduled to end June 2005

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Nitrates

• Nitrates arise from a number of environmental and
  industrial sources which include fertilizers,
  nitrogen concentrating plants, contaminated well
  water, and various organic nitrate drugs.
• Toxicity often combined with other metals bound
• The toxicity of nitrates is due to in vivo
  conversion to nitrites. Chronic ingestion of more
  than 5 mg/kg/day is considered unacceptable.
  Primary overdose effects include orthostatic
  hypotension and methemoglobinemia.

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Nitrates

• Orthostatic hypotension and reflex tachycardia
  are common headache, nausea and vomiting may
  also occur. Methemoglobinemia may develop,
  particularly in infants. In severe poisonings
  unconsciousness, dizziness, fatigue, shortness of
  breath, and hypotension may occur.
• Many nitrates are irritating to mucous membranes.

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Lead

• One of the most common preventable environmental
  health problems in the world
• Definition of harmful levels has changed
  dramatically over the last 30 years
• Decline in last 20 years, but estimated 890,000
  children with elevated blood lead.
• Lead binds to sulfhydryl groups altering the
  structure and function of proteins and activity
  of enzymes (heme synthesis) at low levels in the
  body.

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Lead in Kansas

• Lead-based paint is a major source of lead
  exposure for children in Kansas.
• Forty-two percent of housing in Kansas is
  pre-1960.
• Thirty percent of the target age group lives in
  counties that contain 50 or more pre-1960
  housing
• The Centers for Disease Control and Prevention
  (CDC) estimated 6,400 children in the at-risk age
  group of 6 to 72 months have blood lead levels
  above 10 micrograms per deciliter ( mg/dL).

Kansas Department of Health and Environment
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Lead

• Exposure by ingestion or inhalation
• Lead paint is most important threat for children.
• Also found in dust, soil, drinking water, folk
  remedies, old ceramic cookware, pottery, imported
  cosmetics, parental occupations, home
  renovations.
• Children at risk secondary to pica, inadequate
  nutrition, developmental disabilities.

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Lead - Toxic Effects

• Subclinical
• lower IQ scores, behavioral changes (inattentive,
  hyperactive, disorganized), decreased growth,
  decreased hearing
• Clinical
• anemia, headaches, abdominal pain, loss of
  appetite, constipation, clumsiness, agitation,
  decreased activity, somnolence, and convulsions

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Mercury

• Heavy metal that occurs in three forms
  (elemental, inorganic salts, and organic
  compounds)
• Environmental contamination results from mining,
  smelting, and industrial discharges. Mercury in
  water can be converted by bacteria to organic
  mercury (more toxic) in fish.
• Can also be found in thermometers, dental
  amalgams, fluorescent light bulbs, disc
  batteries, folk remedies, chemistry sets and
  vaccines.
• Heavy metal poisoning is a reportable condition
  in Kansas.

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Mercury - Exposure

• Elemental
• liquid at room temperature that volatizes readily
• rapid distribution in body by vapor, poor in GI
  tract
• Inorganic
• poorly absorbed in GI tract, but can be caustic
• dermal exposure has resulted in toxicity
• Organic
• lipid soluble and well absorbed via GI, lungs and
  skin
• can cross placenta and into breast milk

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Elemental Mercury

• At high concentrations, vapor inhalation produces
  acute necrotizing bronchitis, pneumonitis, and
  death.
• Long term exposure affects CNS.
• Early insomnia, forgetfulness, anorexia, mild
  tremor
• Late progressive tremor and erethism (red
  palms, emotional lability, and memory impairment)
• Salivation, excessive sweating, renal toxicity
  (proteinuria, or nephrotic syndrome)
• Dental amalgams do not pose a health risk.

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Inorganic Mercury

• Mercuric oxide commonly found in schools
• Gastrointestinal ulceration or perforation and
  hemorrhage are rapidly produced, followed by
  circulatory collapse.
• Breakdown of mucosal barriers leads to increased
  absorption and distribution to kidneys (proximal
  tubular necrosis and anuria).
• Acrodynia (Pink disease) usually from dermal
  exposure
• maculopapular rash, swollen and painful
  extremities, peripheral neuropathy, hypertension,
  and renal tubular dysfunction.

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Organic Mercury

• Toxicity occurs with long term exposure and
  effects the CNS.
• Signs progress from paresthesias to ataxia,
  followed by generalized weakness, visual and
  hearing impairment, tremor and muscle spasticity,
  and then coma and death.
• Teratogen with large chronic exposure
• Asymptomatic mothers with severely affected
  infants
• Infants appeared normal at birth, but psychomotor
  retardiation, blindness, deafness, and seizures
  developed over time.
• Jury is out on effects with low or intermittent
  exposure

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Mercury - Prevention

• Many mercury compounds are no longer sold in the
  United States.
• Elemental mercury spills
• Roll onto a sheet of paper and place in airtight
  container
• Use of a vacuum cleaner should be avoided
  because it causes mercury to vaporize
• Consultation with environmental cleaning company
  is advised with large spills.
• State advisories on public limit or avoid
  consumption of certain fish from specific bodies
  of water.

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Chromium

• Used extensively for electroplating, primers,
  corrosion inhibitors, catalysts and wood
  preservatives.
• Primary routes of toxicity are via the lungs, GI
  tract, and skin.
• Irritating and corrosive to skin and mucous
  membranes. Contact dermatitis common.
• Systemic effects include acute renal tubular
  necrosis, hemolysis, and liver damage.
• Long term effects include bronchitis, sinusitis,
  asthma, renal problems, and cancer.

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Cadmium

• Used for electroplating, arts and crafts,
  jewelry manufacture, photography, and food.
• Inhalation and ingestion most common.
• Ingestion causes nausea, vomiting, diarrhea and
  gastritis in large doses.
• Acute effects of inhalation include delayed
  chemical pneumonitis with accompanying noncardiac
  pulmonary edema.
• Chronic effects include renal dysfunction,
  chronic lung disease, reproductive effects and
  cancer.

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Silver

• Used in the manufacture of jewelry, mirrors,
  tableware, ornaments, and in photography. May be
  alloyed with chromium or cadmium.
• One of the most common effects of metallic silver
  toxicity is argyria, a blue-gray discoloration of
  the skin, mucous membranes, and conjunctiva,
  cornea, or lens. Other than argyria, silver
  appears to be of low toxicity.
• Some silver salts are irritating to the mucous
  membranes of the eyes, nose, throat, and
  respiratory tract.

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Silver Nitrate

• Used in the manufacture of silver chloride,
  photographic sensitive materials, photographic
  plating, mirrors, catalysts, and pharmaceuticals.
  It may also be used in photographic dark rooms.
• Silver nitrate is a strong mucous membrane
  irritant-corrosive. It has toxicity due to its
  silver component (argyria), its nitrate component
  (methemoglobinemia), and its corrosive nature.
• Irritant, astringent, or corrosive properties are
  dependent on concentration and duration of
  exposure

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Arsenic

• Multiple sources including dyes, metallurgy,
  medicines, manufacturing, and rodenticides.
• Well absorbed via GI, respiratory and intravenous
  routes.
• Minimal dermal absorption through intact skin,
  but prolonged topical administration can cause
  skin irritation resulting in systemic absorption.
• Multiple forms that cause toxicity including
  metabolites.

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Arsenic

• Signs and symptoms of toxicity vary depending on
  the amount and form ingested the rate of
  absorption, metabolism and excretion and the
  time course of exposure (acute, subacute or
  chronic)
• Acute toxicity begins with gastrointestinal
  symptoms of nausea, vomiting and progressing to
  rice water diarrhea. Symptoms can progress to
  cardiac dysfunction, liver and renal failure,
  encephalopathy and death.
• Chronic symptoms may persist including
  neuropathies.

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Arsenic

• With chronic, low-level exposures
• symptoms such as headache, chronic
  encephalopathy, peripheral sensorimotor
  neuropathy, malaise, cough and peripheral edema
  may occur.
• GI symptoms may be absent.
• Dermatologic lesions can develop.
• Multiple cancers have been associated with
  arsenic exposures.

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Barium

• Highly toxic substance used as a rodenticide and
  male depillatory agent.
• Insoluble forms, such as that used for radiology
  procedures (barium sulfate), are harmless.
• Soluble forms, such as acetate, carbonate,
  chloride, hyrodoxide, nitrate, and sulfide, cause
  profound weakness and GI, neurologic,
  cardiovascular, pulmonary, and, possibly, renal
  dysfunction.

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Benzene

• Used as solvent, as a gasoline additive, and to
  make other industrial chemicals including
  polymers, detergents, pesticides,
  pharmaceuticals, dyes, plastics and resins. It is
  also used as a solvent for waxes, resins, oils
  and natural rubber
• Used for printing, lithography and dry cleaning,
  and in paint, rubber, adhesives and coatings, and
  in detergents
• Used in production of ethylbenzene, cumene and
  cyclohexane
• Used by teens for huffing

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Benzene

• Inhalation
• can cause drowsiness, dizziness, tachycardia,
  headaches, tremors, confusion and unconsciousness
• chronic exposure may cause aplastic anemia and
  leukemia
• Ingestion
• vomiting, tachycardia, staggering gait,
  somnolence, loss of consciousness and delirium,
  followed by chemical pneumonitis and collapse,
  with initial stimulation followed by abrupt CNS
  depression
• Dermal
• strong irritating effect, producing erythema,
  burning and, in more severe cases, edema and
  blistering.

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Cyanides

• Common because of insect kill bottles used in
  past and was used in qualitative analysis since
  the turn of the century
• Hydrogen cyanide was significantly more toxic
  than sodium cyanide or potassium cyanide by IM
  and transocular routes, and potassium cyanide
  significantly less toxic than hydrogen or sodium
  cyanide by skin penetration
• May be fatal if inhaled, ingested or absorbed
  through skin. Inhalation or contact with some of
  these materials will irritate or burn skin and
  eyes.

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Cyanides

• The clinical presentation of the patient depends
  upon the extent of and time since exposure.
• Initially the patient may experience flushing,
  increased heart rate and breathing, headache, and
  dizziness. This then may progress to agitation,
  stupor, coma, apnea, generalized seizures,
  bradycardia, hypotension, pulmonary edema, and
  death.
• Cyanide exposure may produce death within
  minutes. Signs and symptoms following non-lethal,
  subacute, or chronic exposure may include
  syncope, weight loss, headache, dizziness,
  nausea, vomiting, palpitations, confusion,
  hyperventilation, deep inspiratory gasps followed
  by hyperpnea, anxiety, and vertigo. Severe
  hypoxic signs in the absence of cyanosis should
  suggest the diagnosis.

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Cyanides

• Cyanosis is generally a late finding and usually
  does not occur until circulatory collapse and
  apnea are evident, particularly at the premorbid
  stage of cyanide toxicity.
• Mild exposure only causes anxiety, headache,
  nausea, and vomiting.
• Forms a stable complex with iron in the
  cytochrome oxidase enzymes, thereby inhibiting
  (poisoning) cellular respiration.
• All patients should be admitted to the hospital
  following cyanide exposure.

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Explosives

• Diethyl ether and its peroxides are 1 concern
• Is an anesthetic and industrial solvent for fats,
  oils, gums, alkaloids, resins, and waxes. It is
  an important reagent in organic syntheses and
  analytic chemistry.
• Used as a diesel fuel ignition primer
• Ingestion poisonings are similar to ethanol
  overdoses except for a more rapid onset and
  shorter duration of symptoms.
• Inhalation may result in dizziness, giddiness,
  euphoria, and CNS depression. Deaths from acute
  industrial exposure are rare. Death due to
  respiratory depression may result from severe and
  continued exposure.
• Is a severe eye and moderate skin irritant

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Corrosives

• Perchloric acid is most commonly used and
  combined with other metals.
• Used in industrial compounds and in school
  chemistry classes
• Is as strong acid
• Can result in mild to severe chemical burns in
  all routes of exposure depending on concentration
  used.
• Other corrosives include hydrofluoric acid,
  acetic anhydride, and chromyl chloride

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Actions for Schools

• Have regular process that screens and identifies
  problems
• periodic and conscientious
• Health and Safety committee
• oversee the development of policy and the
  operations process
• periodically review program
• Hazard Survey Form
• Contact State Health Department or PEHSU (or
  other resources listed) for help in action plan.

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References

• Pediatric Clinics of North America. October 2001
• Handbook of Pediatric Environmental Health.
  American Academy of Pediatrics. 2003
• www.kdhe.state.ks.us
• www.epa.gov
• www.cdc.gov/nceh
• Americas Children and the Environment. EPA.
  December 2003
• School Health Policy and Practice. American
  Academy of Pediatrics. 2004

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Resources

• Child and Maternal Health Clearinghouse
• [phone]
• National Center for Environmental Health, Centers
  for Disease Control and Prevention
• [phone]
• [phone]
• National Lead Information Center
• [phone]
• Indoor Air Quality Information Clearinghouse
• [phone]

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Resources

• US EPA, Region 7
• [phone]
• EPA Office of Pesticide Program
• (800) 535-PEST (National Pesticide Hotline)
• [phone]
• www.epa.gov/pesticides
• Pesticide Educational Center
• [phone]

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What is a PEHSU?

• Pediatric Environmental Health Specialty Unit
• 11 units in continental United States
• Established in 1998
• Association of Occupational and Environmental
  Clinics
• Agency for Toxic Substances and Disease Registry
• Environmental Protection Agency
• Goal is to increase awareness and knowledge of
  pediatric environmental health

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Mid-America Pediatric Environmental Health
Specialty Unit

• Serve EPA Region 7 (Iowa, Kansas, Nebraska and
  Missouri)
• Serve health care professionals and general
  public
• Consultation
• To physicians and health care providers
• Referral
• To health agencies with an interest in pediatric
  environmental health
• Education Outreach
• Partnership with regional Poison Control Centers

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Mid-America Pediatric Environmental Health
Specialty Unit

• Our Team
• Jennifer Lowry, MD (Toxicologist)
• Kathryn Veal, MD, MPH (Pediatrician)
• H. William Barkman, MD, MSPH (Occupational
  Medicine)
• Mary Walker, Project Coordinator
• [phone] - toll free in EPA Region 7
• Or call the Mid-America Poison Control Center at
  [phone]