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Building Capacity to Address Environmental Health Issues During Pregnancy

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Building Capacity to Address Environmental Health Issues During Pregnancy Melissa Mathias, MPH, CPH, CHES Ohio Department of Health Bureau of Child and Family Health ... – PowerPoint PPT presentation

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Title: Building Capacity to Address Environmental Health Issues During Pregnancy


1
Building Capacity to Address Environmental Health
Issues During Pregnancy
  • Melissa Mathias, MPH, CPH, CHES
  • Ohio Department of Health
  • Bureau of Child and Family Health Services

2
Overview
  • Grant
  • Purpose of Project
  • Environmental Risk Assessment Tool
  • Environmental Hazards
  • Health Effects
  • Exposure Routes
  • Preventative Measures
  • Evaluation
  • Resources

3
Building Capacity to Address Environmental Issues
During Pregnancy
  • Funded by the U.S. Environmental Protection
    Agency
  • Ohio is one of five recipients
  • Four pilot sites
  • Lucas County Regional Health District  CFHS
    Program
  • Public Health-Dayton Montgomery County CFHS
    Program
  • Stark County Health Dept. CFHS Program
  • Athens County CFHS Program (Ohio University)

4
Purpose
  • Address environmental health issues during the
    prenatal period
  • Increase the capacity of health professionals
  • Ensure that all women of childbearing age have
    access to information that will help them take
    actions to reduce environmental exposures

5
Why include all women of childbearing age?
  • Approximately half of all pregnancies are
    unintended
  • Assessment of risk even at a prenatal visit
    during the first trimester will occur after the
    babys internal organs have developed
  • Pre-conception programs are important because
    many environmental agents can cause birth
    defects, cancer and other health problems

6
Gathering Information
  • Provider Survey
  • Discussion Groups
  • Pilot Site Pre-test

7
Provider Survey
  • Sent to OB/GYN, Family Practice and General
    Practice
  • 372 received
  • Areas in need of education
  • Radon
  • Pesticides
  • Arsenic
  • Usually spend 1 to 2 minutes assessing and
    education on environmental risk

8
Provider Survey
  • Main barriers
  • Lack of time during visit
  • Lack of printed material to give the patient
  • Unclear screening guidelines
  • Lack of knowledge about environmental risk
  • Want to know
  • About specific environmental risks
  • How to get brochures or other information
  • What to do if patient is exposed to an
    environmental risk

9
Discussion Groups
  • No system in office to track whether clients are
    screened and treated for environmental risks
  • Types of support needed
  • Standardized environmental screening checklist
  • Websites with additional information
  • Workbook on how to screen and refer women for
    environmental risk
  • Smoking is greatest perceived risk

10
Pilot Site Pre-test
  • Primarily screen for tobacco use.
  • Spend 1 to 2 minutes assessing and 1 to 2 minutes
    educating on environmental risk
  • Dont have sufficient time to assess clients
    environmental risk
  • Dont have the resources needed
  • Agreed that environmental exposures are important
    risk factors for women of reproductive age

11
Pilot Site Pre-test
  • Dont know where to refer clients who are at risk
  • Needed education on all topics, except smoking
  • Offices dont have formally adopted clinical
    guidelines for addressing environmental issues

12
Environmental Risk Assessment Tool
  • Self-administered by patient
  • One page
  • 17 questions
  • Yes, No, Dont Know
  • Sidebar of suggested follow-up actions for health
    care providers
  • Box at bottom to check if patient is willing to
    participate in future evaluation

13
Environmental Risk Assessment Tool
  • Arsenic
  • Cadmium
  • Carbon Monoxide
  • Lead
  • Mercury
  • Mold
  • Pesticides
  • Radon
  • Tobacco

14
Discussion
  • Who is going to give the assessment tool to the
    patient?
  • How is the assessment tool going to end up in the
    chart after it is filled out by the patient?
  • Who is going to discuss the answers with the
    patient? (nurse, health educator, physician, etc.)

15
Arsenic
  • Arsenic can cross the placenta and is found in
    low levels in breast milk
  • Health Effects
  • Exposure in the womb may increase mortality in
    young adults
  • Preterm birth
  • Inorganic arsenic is a known human carcinogen
  • Increased risk of type 2 diabetes in adults
  • Animal studies have shown
  • Low birth weight
  • Fetal malformations
  • Fetal death

16
Arsenic
  • Exposure Routes
  • Occupational
  • Water
  • Pressure-treated Wood

17
Occupational Exposure
  • 2) Do you work with (job or hobby) or live near a
    place that produces any of the following
    pressure-treated wood, smelting, glass
    production, pesticides?
  • If yes, provide education

18
Water Exposure
  • 4) If you use well water, has the water been
    tested for environmental hazards?
  • If no or dont know, water testing is suggested
  • If water comes from a water company or utility
    (often referred to as public water), then the
    water is already being tested and the testing
    results are open to the public.
  • Results can be obtained from the water company or
    utility.

19
Water Testing
  • If water comes from a private well, then it is up
    to the individual to test their water.
  • The U.S. EPAs standard for arsenic concentration
    in water systems is10 µg/L (10 ppb).
  • Patient Referral List

20
Pressure-treated Wood
  • 5) Do you have a deck, patio furniture, bench or
    picnic table made of wood that was built before
    2004?
  • If yes, provide education
  • Inorganic arsenic compounds are used to preserve
    wood.
  • Copper chromated arsenate (CCA) is used to make
    pressure-treated lumber.

21
Preventative Measures
  • Wash hands after contact
  • Annual application of wood sealant
  • Covering surfaces such as picnic tables with a
    tablecloth to prevent contact
  • Be aware that children can be exposed through
    wood playground equipment
  • Do not burn pressure-treated wood

22
Literature/Brochures
  • Arsenic
  • ODH is creating a brochure that addresses that
    threat of arsenic in water and pressure-treated
    wood.

23
Cadmium
  • Can cross the placenta and is transferred through
    breast milk
  • Health Effects
  • Increase risk of early delivery which leads to
    lower birth weight.
  • Decreased fetal growth (lower birth height)
  • Pulmonary irritation
  • Kidney disease
  • Animal studies indicate
  • Impaired neurological development
  • Interference with fetal metabolism

24
Cadmium
  • Exposure Routes
  • Occupational
  • Smoke (First and Secondhand Exposure)

25
Occupational Exposure
  • 2) Do you work with (job or hobby) or live near a
    place that produces any of the following
    smelting, soldering, welding, electroplating,
    pigments, plastics, battery manufacturing?
  • If yes, provide education

26
Smoke First and Secondhand Exposure
  • 6) Does anyone smoke in your home or car?
  • If yes, provide education

27
Preventative Measures
  • Caution at work (wash hands, wear protective
    mask/gloves)
  • Wash hands often when working
  • Quit smoking
  • If you cant quit, smoke fewer cigarettes
  • Eat a balanced diet
  • Iron

28
Literature/Brochures
  • Cadmium
  • Quit Smoking for Baby and You

29
Carbon Monoxide
  • Pregnant women and fetuses are included in the
    most susceptible groups.
  • Health Effects
  • Low birth weight
  • Fetal death
  • Development disorders
  • Chronic cerebral lesions (can cause seizures)
  • For clients
  • Headache
  • Dizziness
  • Nausea
  • Disorientation

30
Carbon Monoxide
  • Exposure Routes
  • Smoke (First and Secondhand Exposure)
  • Combustion Products

31
Smoke First and Secondhand Exposure
  • 6) Does anyone smoke in your home or car?
  • If yes, provide education

32
Combustion Products
  • 9) Do you use your cooking stove/oven or a
    kerosene/gasoline space heater to heat your home?
  • If yes, provide education with a focus on proper
    ventilation

33
Preventative Measures
  • Choose vented appliances whenever possible
  • Never use a gas range, oven or unvented gas or
    kerosene space heater to heat a home
  • Never run your car in a closed garage
  • Make sure that fuel burning appliances are
    working properly
  • Never use a charcoal grill or portable camping
    stove inside a home, tent or camper
  • Never use generators or other gasoline-powered
    tools indoors, in a garage or in a basement.

34
Literature/Brochures
  • Carbon Monoxide
  • CDCs Prevention Guidelines
  • English and Spanish

35
Safety Concerns
  • 7) Does your home have a working smoke detector?
  • 8) Does your home have a working carbon monoxide
    detector?
  • If no, recommend installation of smoke and/or
    carbon monoxide detector

36
Lead
  • Lead crosses the placenta freely and is
    transferred through breast milk
  • Health Effects
  • Elevated blood pressure for the mother
  • Moderate levels
  • Neurobehavioral impairment
  • Preterm birth
  • Decreased gestational maturity
  • Lower birth weight
  • Minor congenital anomalies
  • High levels
  • Abortion

37
Lead
  • Exposure Routes
  • Occupational
  • Water
  • Pre-1978 deteriorated housing
  • Previous exposure
  • Traditional folk remedies and cosmetics

38
Occupational Exposure
  • 2) Do you work with (job or hobby) or live near a
    place that produces any of the following
    soldering, auto repair, plumbing, stained glass,
    pottery making, renovation/restoration/constructio
    n, battery/machinery manufacturing?
  • If yes, provide education

39
Water Exposure
  • 4) If you use well water, has the water been
    tested for environmental hazards?
  • If no or dont know, water testing is suggested

40
Water Testing
  • If water comes from a water company or utility
    the water is already being tested.
  • Results can be obtained from the water company or
    utility.
  • If water comes from a private well, then it is up
    to the individual to test their water.
  • The U.S. EPAs standard for lead in water systems
    is15 µg/L (15 ppb).
  • Patient Referral List

41
Deteriorated Housing
  • 10) Do you live in or regularly visit a house
    built before 1978 that has been recently
    renovated/repaired or has peeling/chipped paint?
  • If yes, suggest a lead risk assessment and
    provide education on wet cleaning methods and

42
Preventative Measures
  • If the home has peeling or chipping paint, a lead
    risk assessment would be a good suggestion
  • Patient Referral Sheet
  • Use a HEPA vacuum
  • Use wet cleaning methods

43
Wet Cleaning Methods
  • With gloves, pick up large paint chips
  • Remove small paint chips by spraying with water
    and sweeping them up into a plastic bag
  • Using two buckets, fill one with water and one
    with water and detergent
  • Work from high to low
  • Clean surface and then rinse
  • Dispose of water in toilet and throw away sponges
    and mops

44
Previous exposure
  • 11) Have you or your children had lead poisoning?
  • If yes, recommend a diet high in calcium and iron
  • If a woman has previously had lead poisoning, the
    lead can mobilize during pregnancy.
  • A diet high in calcium and iron can keep the lead
    from leaching out of the bones.

45
Traditional Folk Remedies and Cosmetics
  • 12) Do you use any traditional folk remedies or
    cosmetics (Alkohl, Azarcon, Bali goli, Ghazard,
    Greta, Pay-loo-ah)?
  • If yes, provide education, cultural awareness is
    a key factor in this question
  • Azarcon and Greta
  • Surma and Kohl

46
Preventative Measures
  • Use proper protective measures at work (gloves,
    mask, etc.)
  • Test your well water for lead
  • Use cold water for drinking and cooking
  • Use wet cleaning methods
  • Take shoes off at door
  • Wash hands often
  • Use a HEPA vacuum, if possible
  • Eat a balanced diet (calcium and iron)
  • Do not use traditional folk remedies or cosmetics

47
Literature/Brochures
  • Lead
  • Pregnancy, Lead and Your Baby
  • Step-by-Step Cleaning to Control Lead Dust in
    Your Home

48
Mercury
  • Mercury in the mothers body passes to the fetus
    and can accumulate there
  • Passes to infant through breast milk
  • Health Effects
  • Neurological disorders
  • Damage the digestive system
  • Kidney damage
  • Stillbirth

49
Mercury
  • Exposure Routes
  • Occupational
  • Traditional folk remedies, cosmetics or rituals
  • Fish
  • Consumer products (thermometers, neon and compact
    fluorescent light bulbs)

50
Occupational Exposure
  • 2) Do you work with (job or hobby) or live near a
    place that produces any of the following
    products of electrolysis, electrical apparatus
    catalysts, dental office?
  • If yes, provide education

51
Traditional folk remedies, cosmetics or rituals
  • 12) Do you use any traditional folk remedies or
    cosmetics (Azogue)?
  • If yes, provide education, cultural awareness is
    an important aspect of this question
  • People who practice Espiritismo, Santeria or
    Voodoo
  • Carry mercury in pouches as a charm
  • Swallow it in drinks or as capsules
  • Sprinkle it around a childs bed or inside a car
    for protection
  • Burn it in candles to ward off evil spirits,
    bring good luck or for love spells

52
Fish Exposure
  • 13) Do you eat more than 12 ounces of cooked fish
    per week (typical serving is 3-6 oz.) 1 can (6
    oz.) of albacore (white) tuna per week or fish
    from Ohio lakes/rivers?
  • If yes, provide education on how fish consumption
    is important, but that certain types of fish
    should be avoided.

53
Preventative Measures
  • Fish is important to a healthy diet
  • Eat
  • Shrimp
  • Canned light tuna
  • Salmon
  • Pollock
  • Catfish
  • Dont eat
  • Albacore (white) tuna (can eat up to 6 oz. a
    week)
  • Shark
  • Swordfish
  • King Mackerel
  • Tilefish
  • Be aware of fish advisories for locally caught
    fish

54
Consumer Products
  • 14) Do you have any mercury thermometers, neon or
    compact fluorescent light bulbs (energy efficient
    bulbs) in your home?
  • If yes, provide education on mercury clean-up and
    recycling options.

55
Preventative Measures
  • Recycle CFLs (Home Depot)
  • Be careful when handling consumer products that
    contain mercury
  • Clean up properly if mercury is spilled
  • http//www.epa.gov/mercury/spills/index.htm
  • If a large amount of mercury is spilled
  • Leave area
  • Call your local or state health or environmental
    agency

56
Cleaning Up a Mercury Spill
  • Air out room for 15 min. before cleaning
  • Pregnant women and children should be kept away
    from the spill
  • Never use a vacuum to clean up mercury
  • Never pour mercury down a drain
  • Put on gloves

57
Cleaning Up a Mercury Spill
  • Scoop up glass and powder with stiff paper or
    cardboard or pick up liquid mercury with an eye
    dropper and place in sealed plastic bag
  • Wipe the area clean with damp paper towels
  • Place used paper towels in plastic bag.
  • Throw away clothes and carpets that come into
    contact with mercury
  • Immediately place all trash outdoors in a covered
    trash container
  • Wash hands after cleaning

58
Literature/Brochures
  • Mercury
  • EPAs Fish Keychain
  • Energy Stars Compact Fluorescent Light Bulbs
    and Mercury
  • What You Need to Know about Mercury in Fish and
    Shellfish
  • English and Spanish

59
Mold
  • Health Effects
  • Asthma
  • Chronic hypertension
  • Preterm birth
  • Low birthweight infants

60
Exposure Route
  • 15) Have you noticed any leaks, damp areas,
    stains, discoloration, gray-black powder (mildew)
    or a strong musty smell in your home?
  • If yes, provide education on
  • identifying source and how to properly
  • clean-up mold.
  • If problem is severe or a pregnant woman has no
    one to clean-up the problem for her, it is
    recommended that she be referred to a
    mold-removal professional

61
Preventative Measures
  • Fix leaks as soon as possible
  • Use the fans/vents in the bathroom and kitchen
    when they are in use
  • Direct gutters away from building to prevent
    water from entering house
  • Dry damp or wet items within 24-48 hours to avoid
    mold growth.
  • If damp items cant be cleaned, throw them out

62
To Clean Up Mold
  • Identify problem
  • Fix problem
  • Dry anthing that is wet
  • Throw out furniture, carpet and other items that
    cant be cleaned
  • Clean solid surfaces
  • Scrub with water/detergent mix
  • Rinse area with clean water
  • If desired, disinfect surfaces with bleach/water
    mix
  • For large problems, contact a professional

63
Literature/Brochures
  • Mold
  • HUD brochure
  • A Brief Guide to Mold, Moisture and Your Home

64
Pesticides
  • 75 of U.S. households used at least one
    pesticide product indoors during the past year
  • Pesticides easily pass through the placenta
  • Health Effects
  • Preterm birth
  • Stillbirth
  • Elevated risk of birth defects
  • Cleft lip and palate, limb defects, heart
    malformations and spina bifida

65
Pesticides
  • 16) Do you use pesticides (rat poison bug
    sprays/baits flea/tick sprays, powders and pet
    collars weed killers) in or around your home?
  • If yes, provide education on Integrated Pest
    Management (IPM)
  • Women who live in rural, agricultural
  • areas could be at a greater risk due to
  • crop spraying and dusting.

66
Integrated Pest Management (IPM)
  • Starve them out
  • Store food in closed containers
  • Clean up spills and crumbs
  • Clean dirty dishes right away
  • Keep a lid on your trash can
  • Dont leave pet food out overnight

67
Integrated Pest Management (IPM)
  • Dry them out
  • Never let water sit in sink overnight
  • Wipe up spills right away
  • Fix any leaky faucets or other appliances
    immediately
  • Keep them out
  • Seal cracks and holes
  • Clean up clutter where pests can hide
  • Use sticky traps and baits

68
If you must use pesticides
  • Use them according to manufacturers directions
  • Use limited quantities
  • Place in area that is out of the reach of
    children and animals

69
Literature/Brochures
  • Pesticides
  • Preventing Pests at Home
  • English and Spanish

70
Radon
  • Health Effects
  • Radon is the second leading cause of lung cancer
    in the United States.
  • It is the leading cause of lung cancer among
    non-smokers
  • Cancer risk is dependent on
  • How much radon is in your home
  • Amount of time spent at home
  • Whether you are a smoker or not

71
  • Red
  • Highest
  • potential
  • for
  • dangerous
  • level (gt4 pci/L)
  • Orange
  • Moderate
  • potential
  • for
  • dangerous level (2-4 pCi/L)

72
Radon
  • Exposure Routes
  • Indoor air
  • Water

73
Indoor Air
  • 3) If you have a basement or crawlspace, has your
    home been tested for radon?
  • If no or dont know, radon testing is suggested

74
Preventative Measures
  • Stop smoking to reduce lung cancer risk
  • Ventilate your home
  • Seal cracks in floors or
  • walls with plaster or caulk
  • If you have high levels,
  • consider installing a radon
  • mitigation system
  • Patient Referral List

75
Water Exposure
  • 4) If you use well water, has the water been
    tested for environmental hazards?
  • If no or dont know, water testing is suggested
  • Patient Referral List
  • Point of entry treatment
  • Point of use treatment

76
Literature/Brochures
  • Radon
  • HUD brochure
  • A Citizens Guide to Radon
  • Home Buyers and Sellers Guide to Radon
  • English and Spanish

77
Tobacco
  • Cigarette smoking during pregnancy is the leading
    environmental factor for adverse pregnancy
    outcome.
  • Nicotine is found in breast milk
  • Between 12 and 20 percent of all pregnant women
    smoke

78
Tobacco
  • Health Effects
  • Low birth weight
  • Preterm delivery
  • Spontaneous abortion
  • Risk factor for
  • SIDS (Sudden Infant Death Syndrome)
  • Ear infections
  • Asthma

79
Tobacco
  • 6) Does anyone smoke in your home or car?
  • If yes, provide education
  • Follow the 5As
  • Ask, Advise, Assess, Assist, Arrange
  • Dont Smoke
  • Smoke less, if you cant quit
  • Avoid being around other people who smoke
  • Literature is previously mentioned Quit Smoking
    for Baby and You

80
Other Questions
  • 1) Are you pregnant or do you plan on being
    pregnant within the next year?
  • 17) Do you rent or own your home/apartment?

81
Literature/Brochures
  • General
  • A Clean Home is a Healthy Home
  • Help Yourself to a Healthy Home Bookmark
  • Make Your Home a Healthy Home DVD

82
Ordering More
  • Please ask us if you need more literature,
    brochures, or anything else.
  • We would be happy to order more for you
  • EPAs National Service Center for Environmental
    Publications (NSCEP)
  • www.epa.gov/nscep
  • Call 800-490-9198
  • Fax 301-604-3408
  • Literature Websites

83
Evaluation
  • Pilot site
  • Post-test
  • Chart review
  • Patients
  • Focus groups
  • Chart reviews
  • When you start using the assessment tool, please
    keep a list of women who would be willing to be a
    part of our evaluation

84
Incentives
  • Women
  • Carbon Monoxide/Smoke Alarm
  • Radon Test
  • Lead Check Swabs
  • Office
  • Literature Rack
  • Literature folders

85
Resources
  • Ohio Department of Health
  • www.odh.ohio.gov
  • U.S. Environmental Protection Agency
  • www.epa.gov
  • U.S. Centers for Disease Control and Prevention
    (CDC)
  • www.cdc.gov/Environmental
  • Department of Housing and Urban Development (HUD)
  • www.hud.gov/offices/lead/healthyhomes

86
  • Questions?

87
  • Please fill out your evaluation form before you
    leave.
  • Thank you!

88
Lead Check Swabs
  • If it is red, there is lead

89
If you have any questions or concerns, please
feel free to contact me
  • Melissa Mathias
  • Melissa.mathias_at_odh.ohio.gov
  • 614-466-4113
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