How to Incorporate Environmental Health into Your Primary Care Practice

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1 How to Incorporate Environmental Health into Your Primary Care Practice SUSAN BUCHANAN, MD, MPH UNIVERSITY OF ILLINOIS AT CHICAGO SCHOOL OF PUBLIC HEALTH MARCH 2017

2 Disclosures I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

3 Learning Objectives Screen patients for selected environmental exposures which are linked to asthma, learning disabilities, and behavior disorders Advise families about how to reduce environmental exposures at home

The findings and conclusions in this presentation have not been formally disseminated by the Agency for Toxic Substances and Disease Registry and should not be construed to represent an agency

4 The findings and conclusions in this presentation have not been formally disseminated by the Agency for Toxic Substances and Disease Registry and should not be construed to represent an agency determination or policy. Acknowledgement: The U.S. Environmental Protection Agency (EPA) supports the PEHSU by providing partial funding to ATSDR under Inter-Agency Agreement number DW Neither EPA nor ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications. Credit to National Environmental Education Foundation (NEEF) for some of the asthma slides Helen Binns, MD, MPH for some of the lead slides

5 Pretest The second leading cause of lung cancer (after tobacco smoking) is: A. marijuana smoking B. secondhand tobacco smoke C. radon D. air pollution

6 Pretest Regarding maternal blood lead during pregnancy: A. Very little crosses the placenta 5:1 ratio B. Action level is 15 ug/dl C. Does not cross into breast milk D. May be elevated with pica

7 Pretest AQI stands for: A. Air Quality Index B. Asthma Quality Initiative C. Atmospheric Qualifying Ion D. Allergen Quick Impactor

8 What is Environmental Medicine? If you want to learn about the health of a population, look at the air they breathe, the water they drink, and the place that they live. Air, Water, Places Hippocrates

9 Air Particulates Carbon monoxide Ozone Sulfur dioxide Nitrogen oxides Chemicals Radon

10 Water Microbials Chemical contamination Lead

11 Place Lead Carbon monoxide Mold and moisture Formaldehyde Cigarette/marijuana smoke Asbestos Radon Pesticides

12 Food Bacterial food poisoning Organic mercury, arsenic Pesticide residues Persistent organic pollutants

13 Children as High Risk Population Developing brain Higher absorbed dose Different physiology Different diets Longer life span High risk behaviors Children are not little adults

14 Patient Questions I ve heard a lot about lead in the water. Should you be testing my kids for lead? We ve been living with my mother and she just died of lung cancer. But she never smoked. Did something in the home cause it? What s making my child s asthma so bad?

15 I ve heard a lot about lead in the water. Should you be testing my kids for lead?

16 How are children exposed to lead? Mouthing activities Paint flakes and contaminated dust windows, porches Soil Near buildings, under porches Track-in Drinking water service lines, brass fittings

17 U.S. Housing-based Lead Paint Risk 100% 80% 66% 86% 67% 60% 40% 20% 0% 7% 25% 11% 3% 39% Pre1940 Lead-Based Paint Significant LBP Hazard American Healthy Homes Survey (AHHS), 2011

18 Other Sources

Health Effects of Blood Lead National Toxicology Program - NIH At mean blood lead levels < 5ug/dl Sufficient evidence for: Attention-related problems

19 Health Effects of Blood Lead National Toxicology Program - NIH At mean blood lead levels < 5ug/dl Sufficient evidence for: Attention-related problems Greater incidence of problem behaviors Decreased cognitive performance National Toxicology Program Monograph on Health Effects of Low-Level Lead 2012

Low-Level Environmental Lead Exposure and Children s Intellectual Function: An International Pooled Analysis Pooled analysis, 7 studies, N= 1,333 Increase

20 Low-Level Environmental Lead Exposure and Children s Intellectual Function: An International Pooled Analysis Pooled analysis, 7 studies, N= 1,333 Increase in lead: from 2.4 to 10 g/dl 3.9 IQ pts from 10 to 20 g/dl 1.9 from 20 to 30 g/dl 1.1 Lanphear et al, Environ Health Perspect July; 113(7):

How much does lead in drinking water contribute to blood lead? Sig. association between lead in tap water and BLL (OR 4.7, CI 2.1-10.2) [Levallois 2014] and p< 0.

22 How much does lead in drinking water contribute to blood lead? Sig. association between lead in tap water and BLL (OR 4.7, CI ) [Levallois 2014] and p< 0.05 [Lanphear 1998] After 5 months of exposure to lead in tap water: mean BLL 35% [Ngueta 2016] For bottle-fed infants water contribution to BLL may be > 50% [US EPA] No known reports of community mean BLL over level of concern due to contaminated drinking water (Pb in plumbing) National Toxicology Program Monograph on Health Effects of Low-Level Lead 2012

23 Screening Requirements in Illinois: Physicians are required to test all children between 6 months and 7 years of age if they reside in a high-risk area Child care facilities, preschools and kindergartens must require each parent or legal guardian of a child between 6 months and 7 years of age to provide a statement from a health care provider that the child has been risk evaluated if the child resides in an area defined as low risk by the Department or tested for lead poisoning if the child resides in an area defied as high risk. testing-case-management

26 East Chicago, Indiana

27 Preventing Lead Exposure Identify lead hazards Avoid (esp. windows, porches) Clean up Fix up (safely) Identify child risks Oral behaviors Low iron (screen with ferritin, not Hgb) Sensible measures Wash hands before food handling Shoes off at door Cold, flushed water Avoid other sources of lead (occupational take home, hobbies)

28 Promote Nutritional Health Treat iron deficiency Vitamin C iron absorption Ensure Recommended Daily Allowance Calcium Provide daily multivitamin with iron Enhanced absorption of lead after prolonged fast (so eat breakfast) *Solon et al. J Pediatr 2008;152:237-43)

29 Language Enrichment Begin in early months of life Provide quantity TV is NOT a substitute Attend to quality of language Simple (but stretching), use repetition, enunciate Conversation (allow the child to talk to you) Listen Be positive (do not correct a child s speech) Reading (vocabulary, use of book to start conversation); effect of reading evident by age 2

30 Blood Lead in Pregnancy Fetus/Infant Blood Lead 1:1 with maternal blood lead Maternal Blood Fall in BLL from weeks Rising levels weeks

31 Other Sources

32 Children s IQ and Maternal Lead Study from Mexico 150 children BLL in pregnancy = geometric mean 8.0 g/dl Maternal blood lead at 28 wks gestation significantly assoc with child IQ at age 6-10 yrs Schnaas; Env Health Perspect 2006;114:791-7

Eat/chew on non-food items Minnesota HD 1. Use of pottery or lead crystal 2.

33 Screening Questions for Pregnant Women NYC 1. Born/spent time outside of US 2. Last 12 mos, use imported remedies, spices, foods, ceramics, cosmetics 3. Eat/chew on non-food items Minnesota HD 1. Use of pottery or lead crystal 2. Home/folk remedies or cosmetics 3. Eat non-food items 4. Last 12 mos, renovation 4. Renovations if built before Ever had job/hobby with lead exposure 5. Occupation 6. Hobbies 7. Water tested and is high

34 We ve been living with my mother and she just died of lung cancer. But she never smoked. Did something in the home cause it?

36 Radon Radon is estimated to cause about 21,000 lung cancer deaths per year Leading cause of lung cancer in non-smokers Second leading cause of lung cancer in smokers EPA's 2003 Assessment of Risks from Radon in Homes (EPA 402-R )

37 Radon Cracks in solid floors Construction joints Cracks in walls Gaps in suspended floors Gaps around service pipes Cavities inside walls

38 Radon Nearly 1 out of every 15 homes in the U.S. is estimated to have elevated radon levels. EPA and the Surgeon General recommend testing all homes below the third floor for radon. EPA also recommends testing in schools.

39 Radon test kits

40 Radon mitigation

41 What s making my child s asthma so bad?

42 National Asthma Education and Prevention Program Expert Panel Report-3: Guidelines for the Diagnosis and Management of Asthma

43 Six Priority Messages 1. Use inhaled corticosteroids 2. Use a written asthma action plan 3. Assess asthma severity 4. Assess and monitor asthma control 5. Schedule periodic asthma visits 6. Control environmental exposures

44 National Survey on Environmental Management of Asthma US Environmental Protection Agency 2004 < 30% of people with asthma are taking all the essential actions recommended to reduce their exposure to indoor environmental asthma triggers.

45 How do environmental exposures cause asthma attacks? Act as triggers in individuals with hyperresponsiveness Worsen airway inflammation Increase the immune response to inhaled allergens

46 Environmental asthma triggers Indoor Pollutants

daycare) Biologic allergens Dust mites Cockroaches Pets Mold ETS Irritant

47 Indoor pollutants may be more important than outdoor pollutants! *Americans spend more than 90% of their time indoors (home, work, school, daycare) Biologic allergens Dust mites Cockroaches Pets Mold ETS Irritant chemicals (cleaners) Particulate matter (combustion: gas stove, wood stove, kerosene heaters

48 Oxides of nitrogen - NOx Gas ranges used for home heating Improperly vented fireplaces Malfunctioning furnaces Wood-burning stoves Poorly-ventilated kerosene or gas space heaters

49 Outdoor air pollution Ozone (ground level) Sulfur dioxide Particulate matter Nitrogen dioxide Respiratory irritation: runny nose, wheezing, sneezing, shortness of breath, throat irritation Asthma exacerbation Angina, CHF exacerbation

50 EPA determines the daily index number Names the critical pollutant Lists the sensitive sub-groups

54 Patient Questions I ve heard a lot about lead in the water. Should you be testing my kids for lead? We ve been living with my mother and she just died of lung cancer. But she never smoked. Did something in the home cause it? What s making my child s asthma so bad?

55 Resources

56 UCSF Program on Reproductive Health and the Environment (PRHE)

58 Pediatric Environmental Health Specialty Units (PEHSU) Funded by federal EPA, ATSDR Staffed by: Occupational/Environ-mental Med physician Peds or Family Med physician Medical toxicologist Pediatric health nurse Industrial hygienist

59 PEHSU Services Provide clinical consultations Telephone consults to health care providers and families Clinic visits at UIC, Stroger Hospital, Cincinnati Children s Hospital, Lurie Children s Memorial Consult to public health and environmental agencies Train physicians, nurses, and other health professionals in children s environmental health

60 Factsheets

61 GreenKidsDoc blog Topics Lead Mercury (organic, elemental) Fluoride Radiation Sun screens Radon Artificial turf Pesticides

62 Great Lakes Center for Children s Environmental Health (Region 5 PEHSU) Region 5 Pediatric Environmental Health Specialty Unit (PEHSU) (312) or (866)

63 Pretest The second leading cause of lung cancer (after tobacco smoking) is: A. marijuana smoking B. secondhand tobacco smoke C. radon D. air pollution

64 Pretest Regarding maternal blood lead during pregnancy: A. Very little crosses the placenta 5:1 ratio B. Action level is 15 ug/dl C. Does not cross into breast milk D. May be elevated with pica

65 Pretest AQI stands for: A. Air Quality Index B. Asthma Quality Initiative C. Atmospheric Qualifying Ion D. Allergen Quick Impactor

66 Questions?

DELAWARE HEALTHY HOMES SUMMIT Children s Health & The Indoor Environment CLAYTON HALL, UNIVERSITY OF DELAWARE NEWARK, DELAWARE

DELAWARE HEALTHY HOMES SUMMIT Children s Health & The Indoor Environment CLAYTON HALL, UNIVERSITY OF DELAWARE NEWARK, DELAWARE JUNE 5, 2012 Healthy Homes, Healthy Children, Healthy Future Presentation