Welcome ….. Introduction to Environmental and Occupational Health Course Instructor: Eric Amster MD MPH …. Let’s start with a story

猫踊り病, neko odori byō 1950

1956 First victim

1957 “An epidemic of an unknown disease of the central nervous system”

1958 Elevated levels of lead, arsenic, manganese, mercury, selenium, thallium

1959 Biomonitoring for Mercury: Hair samples 4 ppm191 ppm 705 ppm Outside Minamata Minamata average Symptomatic

1960 “Minamata disease is rather considered to be poisoning by a heavy metal... presumably it enters the human body mainly through fish and shellfish But where was the heavy metal coming from?

1932, Japan

The Story of Minamata Disease How was the cause of the disease discovered?  Methods in Environmental Epidemiology How did the exposure to mercury occur?  Exposure Assessment What is the toxic effect of mercury?  Toxicology What effect did policy, advocacy, legislation have on the effects of the disease?  Environmental Health Policy

This course will give you a general introduction to the core topics in environmental and occupational health.

Framework of the course 1. Evaluating environmental causes of disease  Exposure Assessment  Environmental/Occupational Epidemiology  Environmental Toxicology  Clinical Toxicology

Framework of the course 2. Environmental exposures  Pesticides  Chemical Hazards  Water Pollution  Physical hazards  Built environment, transportation  Air pollution

Framework of the course 3. Social aspects of EOH  Environmental Health Policy  Pediatric Environmental Health  Vulnerable Populations/Environmental Justice  International Environmental Health  Environmental Health Ethics and Advocacy

Exposure Assessment There is no effect on health without an actual exposure that results in internal dose. The chemical pathway from ambient environmental exposure to biological dose.

Exposure Assessment

Monitoring exposures in the environment Monitoring exposures in humans Modeling the route of exposure Calculating the predicted internal dose

Environmental and Occupational Epidemiology Utilizing epidemiology methods to discover the environmental causes of disease  Case-control, Cohort… what else?

Lecture 2: Environmental and Occupational Epidemiology Sentinel episode, cluster analysis

Environmental and Occupational Epidemiology Review common epidemiological methods in EOH Discuss common sources of bias and error in environmental and occupational epidemiology How to read and analyze environmental and occupational epidemiology literature

Chemical Hazards Review of common occupational and environmental chemical hazards  metals  solvents  persistent organic pollutants Discuss common routes of exposure and related health effects  Inhalation  Ingestion  dermal

Water Pollution Discuss common sources of water pollution Discuss common related health effects from exposure to aquatic toxins

Pediatric Environmental Health Children have higher burden of disease Children have more significant exposures

Pediatric Environmental Health Recognize the physiological and developmental aspects which pose children at risk for environmental exposures. Recognize routes of exposures to children

Pesticides Pesticides are the most ubiquitous environmental exposures. We are exposed in food, water, and air

Pesticides Learn about pesticides – what they are and what are the risks they may pose? Identify the scenarios – where and when are people exposed? Recognize signs, symptoms and diseases that may be related to pesticide exposure Know how to prevent pesticide exposure

Toxicology Toxicology is the laboratory study of the biological effects of chemical exposure. What is the effect on DNA, cells, tissue and organs What is the relationship between dose and response Toxicology describes what is a safe versus hazardous dose

Environmental Health Policy Policy has the single greatest influence on environmental health outcomes

Environmental Health Policy Understand how toxicological data (NOAEL, LOAEL) is used to develop drinking water standards Understand the relationship between air pollution standards and epidemiologic findings regarding the health effects of air pollution Understand how human biomonitoring can inform environmental health policy

Physical Hazards Noise, vibration, temperature, radiation

Physical Hazards Noise, vibration, temperature, radiation Describe basic physiology of exposure to physical hazards List illnesses associated with exposure to physical hazards Discuss prevention and engineering controls of physical hazards Describe differences between ionizing and non- ionizing radiation

Transportation and Health

Describe the current epidemiology of road trauma in terms of use, exposure and risk for all road users. Describe the role of the public health professional in assessment and prevention in urban and rural environments

Indoor and Ambient Air Pollution

Discuss the global burden of disease attributed to air pollution Identify primary pollutants to the indoor and outdoor environments List associated health effects from O3, NOx, SO 2, and PM

International Environmental and Occupational Health

Discussion of case studies in international EOH Apply lessons learned from past failures and successes, with attention to the strengths and limitations of epidemiology Define and use simple tools for assessing human impacts on global environmental sustainability

Ethics and Advocacy Review case scenarios in ethical conflicts common in occupational and environmental health Discuss problem solving conflicts of interests Advocating for environmental and occupational safety and health

Course Text

Course Grading Skill Assignment Grade % Interactive learning 1 hour on-line module. “Approaching Cases of Environmental Exposure ” 10% Oral presentation Critical analysis 10-minute oral critique of epidemiology paper 25% Factual knowledge 50 question multiple choice final exam 65%

Lecture 1: Introduction to Env/Occ Health What is Environmental Public Health What is Occupational Public Health What is the primary difference between the two What is Environmental and Occupational Medicine What is the primary difference with Env/Occ Health

Environmental Public Health The study of the impact which environmental exposure plays on the health outcome of a community.  Environmental Exposure  Outcome  Community

Environmental Public Health Exposure? Outcome? Community?

Environmental Public Health Exposure?  Air pollution Outcome? Community?

Environmental Public Health Exposure?  Air pollution Outcome?  Asthma  Lung Cancer  Birth Defects Community?

Environmental Public Health Exposure?  Air pollution Outcome?  Asthma  Lung Cancer  Birth Defects Community?  People who live in the city

Occupational Public Health The study of the impact which occupational exposure plays on the health outcome of a workers.  Occupational Exposure  Outcome  Worker population

Occupational Public Health Exposure? Outcome? Worker population?

Occupational Public Health Exposure?  Solvents  Metals  Heat  Vibration Outcome? Worker population?

Occupational Public Health Outcome?  Asthma  Lung Cancer  Birth Defects Worker population? Exposure?  Solvents  Metals  Heat  Vibration

Occupational Public Health Outcome?  Asthma  Lung Cancer  Birth Defects Worker population?  Factory workers  Security guards  Family of workers Exposure?  Solvents  Metals  Heat  Vibration

Environmental vs. Occupational Health Environmental  Larger affected population  Smaller concentrations  Fewer exposures  Regional monitoring Occupational  Smaller effected population  Higher concentrations  More exposures  Direct monitoring Occupational health issues become environmental health issues

Environmental Medicine The study of the impact which environmental exposure plays on the health outcome of an individual.  Environmental Exposure  Outcome

Environmental Medicine

Exposure? Outcome? Community?

Environmental Medicine Exposure? Outcome?  Arsenic poisoning  Hyperkeratosis  Anemia  Fatigue  Cancer Community?

Environmental Medicine Exposure?  Arsenic in Tigris River Outcome?  Arsenic poisoning  Hyperkeratosis  Anemia  Fatigue  Cancer Community?

Environmental Medicine Exposure?  Arsenic in Tigris River Outcome?  Arsenic poisoning  Hyperkeratosis  Anemia  Fatigue  Cancer Community?  The patient… but also these guys

Environmental Medicine Key points  There is almost always someone else exposed  If one person is sick look for who else is exposed  Co-workers  Family members  Neighbors  First step is always to get a good exposure assessment.  What do they do at work? Where do they do it? What kind of a house do they live in? Where do they get their water? Their food?

Environmental Public Health 1. Recognizing disease in a specific community 2. Identify environmental exposures in the community 3. Make the connection between exposure and disease 4. Reduce the exposure to pollution

Environmental Public Health Recognizing disease in a specific community  From there was a 6 point drop in average IQ in the US population  In the same period there was a 3 fold increase in cognitive delay  Autism disorders began to be recognized

Environmental Public Health Recognizing disease in a specific community Identify environmental exposures in the community  Multiple different exposures were identified  Advent of TV  Popularity of drugs  Decline of education  Increase in air lead levels

Lead example A heavy metal Found naturally in the environment Has been used by humans for thousands of years.  Used in wine by the Romans  Used in pharmaceuticals by Chinese  Used in gasoline and paint by us Only problem is that it’s a neurotoxin

Lead example Health effects  Neurotoxin  Impedes neurotransmission  Can result in  Autism  Cognitive delay  Reduced IQ

Lead Example: Env Public Health Recognizing disease in a specific community Identify environmental exposures in the community  Increase of air lead levels  During the 1920’s the industrial revolution was at its peak.  Widespread use of fossil fuels for industrialization  Lead was added to fuel as an anti-knocking agent

Lead Example: Env Public Health Recognizing disease in a specific community Identify environmental exposures in the community  Increase of air lead levels  From 1920s to 1970s there was an 18 fold increase in fossil fuel usage  In same time a 11 fold increase in air lead levels

Lead Example: Env Public Health Recognizing disease in a specific community Identify environmental exposures in the community Make the connection between exposure and disease  Epidemiology: the study of disease distribution and cause  Did the exposure precede the disease?  Is the exposure associated with the disease?  Did the exposure cause the disease?

A quick word on causation What’s the difference between causation and association? How do we prove causation?  We can’t! Beware of research that states “caused” and “proved”  Scientific Method  Hill’s Criteria:  Temporality, dose response, biological plausibility, strength of effect, reversal of effect

Lead Example: Env Public Health Recognizing disease in a specific community Identify environmental exposures in the community Make the connection between exposure and disease Reduce the exposure to pollution  In 1970 clean air act was instituted  In 1975 started phasing out lead in gasoline  In 1978 lead was banned from gasoline

Lead Example: Env Public Health

SOURCES: Rick Nevin, National Center for Healthy Housing 2000

Environmental Public Health vs. Medicine Recognizing disease in a specific community Identify environmental exposures in the community Make the connection between exposure and disease Reduce the exposure to pollution Recognize disease in an individual Identify environmental exposure of the individual Make the connection between exposure and disease Reduce the exposure first… Treat the specific disease