32 wd toxic exposures garman.ppt exposures_garman.pdf · 11/6/2008 1 environmental challanges...

11/6/2008

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Environmental Challanges

Bisphenol A (BPA)p ( )

Mold growth/illness

Lead extent/illness

Ray F. Garman, MD MPH

Department of Preventive Medicine and Environmental

Health

UK College of Public Health

11/6/2008

2

BISPHENOL A

In polycarbonate plastics, including some water bottles and baby bottles & lining ofwater bottles and baby bottles, & lining of some canned goods

FDA:: “Safe at typical exposure levels from food and drink”FDA Final Report is not out yet; no comment yet about hormone effects specifically

BISPHENOL A

American Chemistry Council (Plastic Industry Trade Group): If FDA determines that existing margins of safety are insufficient in infant applications, we will

tl h t f BPA i b bpromptly phase out use of BPA in baby bottles and infant formula packaging

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BISPHENOL A

Natural Resources Defense Council: (NRDC):

FDA has consistently ignored science y gand sound policy…It’s time for the FDA to protect infants and pregnant women.

BISPHENOL A

FDA: “… present consensus among regulatory agencies in the United States, Canada, Europe, and Japan is that current levels of exposure to BPA through food packaging do not pose an immediate risk to the general population, including infants and babies”

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BISPHENOL A

CANADA (l t O t b ) BPA b d i b bCANADA (late October): BPA banned in baby bottles

FDA: Canadian action taken “out of abundance of caution” No proof of harm to babies with typical exposureNo proof of harm to babies with typical exposure to BPA

BISPHENOL A

In polycarbonate plastics, including some water bottles and baby bottles & lining ofwater bottles and baby bottles, & lining of some canned goods

FDA:: “Safe at typical exposure levels from food and drink”FDA Final Report is not out yet; no comment yet about hormone effects specifically

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BISPHENOL A

–WHAT TO TELLWHAT TO TELL PATIENTS:

–Still a questionable exposure

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ACOEM HHE with Indoor MoldsACOEM HHE with Indoor Molds

Important Allergens:Important Allergens:

5% ith ll i i t lif ti5% ith ll i i t lif ti5% with allergic airway symptoms lifetime5% with allergic airway symptoms lifetime

May produce MycotoxinsMay produce Mycotoxins

“Current scientific evidence does not support the “Current scientific evidence does not support the proposition that human health has been proposition that human health has been adversely affected by inhaled mycotoxins in adversely affected by inhaled mycotoxins in home, school, or office environments.”home, school, or office environments.”

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MOLD GROWTHMOLD GROWTH

Hydroscopic surfaces support Hydroscopic surfaces support growth, even clay brick and growth, even clay brick and cement if moisture is cement if moisture is sufficiently absorbedsufficiently absorbed

>3>3--4 Molecule depth of water 4 Molecule depth of water required to allow droplets to runrequired to allow droplets to run

IOM Summary of FindingsIOM Summary of Findingsthe Association between Health Outcomes & the Association between Health Outcomes &

Exposure to Damp Indoor Environments Exposure to Damp Indoor Environments

DAMP INDOOR DAMP INDOOR SPACESSPACES

National Academies National Academies PressPress

Washington, DC Washington, DC 20042004

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Particle Board release of Particle Board release of Formaldehyde is increased with Formaldehyde is increased with

increased Relative Humidityincreased Relative Humidityincreased Relative Humidityincreased Relative Humidity

PVC backing on carpet tiles PVC backing on carpet tiles increases release of alcohols with increases release of alcohols with

i d R l ti H iditi d R l ti H iditincreased Relative Humidity increased Relative Humidity

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Association between Health Association between Health Outcomes and Damp Indoor Outcomes and Damp Indoor

EnvironmentsEnvironments

Damp Space Associations:Damp Space Associations:CausalCausal RelationshipRelationship

NONENONE

Association between Health Association between Health Outcomes and Damp indoor Outcomes and Damp indoor

EnvironmentsEnvironments

LimitedLimited or or SuggestiveSuggestive EvidenceEvidence

DyspneaDyspneaAsthma developmentAsthma developmentLower Respiratory Illness in Lower Respiratory Illness in

otherwise healthy children otherwise healthy children

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Association between Health Association between Health Outcomes and Damp indoor Outcomes and Damp indoor

EnvironmentsEnvironmentsInadequateInadequate oror InsufficientInsufficient of Associationof AssociationInadequateInadequate or or InsufficientInsufficient of Associationof Association

Airflow Obstruction in otherwise healthy Airflow Obstruction in otherwise healthy personspersons

COPDCOPDCOPDCOPD

Non Occupational Inhalation FeversNon Occupational Inhalation Fevers

Lower Respiratory illness in otherwise Lower Respiratory illness in otherwise healthy adultshealthy adults

Association between Health Outcomes and Association between Health Outcomes and Damp indoor Environments:Damp indoor Environments:

InadequateInadequate oror InsufficientInsufficient AssociationAssociationInadequateInadequate or or InsufficientInsufficient AssociationAssociationAcute Idiopathic Pulmonary Hemorrhage Acute Idiopathic Pulmonary Hemorrhage in Infantsin Infants

Mucous Membrane Irritation Syndrome Mucous Membrane Irritation Syndrome

Skin, GI, Neuropsychiatric, Reproductive Skin, GI, Neuropsychiatric, Reproductive symptomssymptoms

FatigueFatigue

CancerCancer

Rheumatologic & other immune diseases Rheumatologic & other immune diseases

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Association between Health Association between Health Outcomes with Mold and other Outcomes with Mold and other

Agents in Damp Indoor Agents in Damp Indoor EnvironmentsEnvironmentsEnvironmentsEnvironments

Damp Space Associations:Damp Space Associations:CausalCausal RelationshipRelationship

NONENONE

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Association between Health Association between Health Outcomes and Mold or other Outcomes and Mold or other

agents in Damp Environmentsagents in Damp Environments

S ffi i t E id f A i tiS ffi i t E id f A i tiSufficient Evidence of AssociationSufficient Evidence of Association

Nose & Throat SymptomsNose & Throat Symptoms

WheezeWheeze

CoughCoughgg

Asthma Sx in sensitized asthmatic personsAsthma Sx in sensitized asthmatic persons

Hypersensitivity Pneumonitis in susceptibles Hypersensitivity Pneumonitis in susceptibles



LimitedLimited or or SuggestiveSuggestive AssociationAssociation

Lower Respiratory Illness in Lower Respiratory Illness in p yp yotherwise healthy childrenotherwise healthy children

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Inadequate or Insufficient EvidenceInadequate or Insufficient EvidenceInadequate or Insufficient EvidenceInadequate or Insufficient Evidence--DyspneaDyspnea

--Airflow obstruction in otherwise healthy personsAirflow obstruction in otherwise healthy persons-- COPDCOPD

--Non occupational inhalation feversNon occupational inhalation fevers-- Lower Respiratory Illness in otherwiseLower Respiratory Illness in otherwiseyy

Healthy adultsHealthy adultsAcute Idiopathic Pulmonary Hemorrhage in Infants Acute Idiopathic Pulmonary Hemorrhage in Infants

Association between Biological & Association between Biological & Chemical Exposures and Chemical Exposures and

Exacerbation of Asthma inExacerbation of Asthma inExacerbation of Asthma in Exacerbation of Asthma in Sensitive PersonsSensitive Persons

From: From: Clearing the AirClearing the Air

IOMIOMIOMIOM

20002000

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ASTHMA ASTHMA ASSOCIATION/RELATIONSHIPASSOCIATION/RELATIONSHIP

Biological Agents Chemical AgentsBiological Agents Chemical Agentsg g gg g g

Sufficient Evidence of Causal RelationshipSufficient Evidence of Causal Relationship

Cat ETS in preschoolersCat ETS in preschoolersCat ETS in preschoolersCat ETS in preschoolers

CockroachCockroach

House Dust Mite House Dust Mite

Biological ChemicalBiological Chemical

ASTHMA ASSOCIATION/RELATIONSHIP

Sufficient evidence of an AssociationSufficient evidence of an Association

Dog Dog NONOxx NONO22

Rhinoviruses Rhinoviruses

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Biological ChemicalBiological Chemical

ASSOCIATION/RELATIONSHIPASTHMA

Limited Evidence of an AssociationLimited Evidence of an Association

Domestic Birds ETS is school age, adults Domestic Birds ETS is school age, adults

Chlamydia trachoma is FormaldehydeChlamydia trachoma is Formaldehyde

Mycoplasma pneumoniae FragrancesMycoplasma pneumoniae Fragrances

RSVRSV

BiologicalBiological ChemicaChemicallInadequate or Insufficient Evidence forInadequate or Insufficient Evidence forInadequate or Insufficient Evidence for Inadequate or Insufficient Evidence for AssociationAssociation

Cow, horse PesticidesCow, horse PesticidesRodents PlasticizersRodents PlasticizersChlamydia Trachomatis Chlamydia Trachomatis HouseplantsHouseplantsPollen ExposurePollen Exposure

(in indoor environment) (in indoor environment) Insects other than Cockroaches Insects other than Cockroaches

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Inadequate Evidence of Inadequate Evidence of AssociationAssociation

MucousMucous Membrane Irritation SyndromeMembrane Irritation Syndrome

Skin ,GI, Neuropsychiatric, Reproductive SxSkin ,GI, Neuropsychiatric, Reproductive Sx

FatigueFatigue

CancerCancer

Rheumatologic & other immune diseasesRheumatologic & other immune diseases

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Presence of fungus does not indicate mold Presence of fungus does not indicate mold dddamagedamage

“Indicator Fungi” that exceed outdoor “Indicator Fungi” that exceed outdoor concentration indicate concentration indicate Mold ColonizationMold Colonization


Other IOther Impactsmpacts not Addressednot AddressedppHouse Dust MitesHouse Dust MitesVirusesVirusesTobacco SmokeTobacco SmokeCockroachesCockroachesP ti idP ti idPesticidesPesticidesNONO22 NONOxx

See IOM Report See IOM Report Clearing the Air, 2000Clearing the Air, 2000Indoor Allergens, 1993Indoor Allergens, 1993

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Indicator Fungi:Indicator Fungi:

******Aspergillus fumigatus Aspergillus fumigatus A. versicolorA. versicolorA penecilloides Actinomyctes A penecilloides Actinomyctes

Gram Negative BacteriaGram Negative Bacteria***Penecillium***Penecillium

^St h b t h t^St h b t h t^Stachybotrys chartarum^Stachybotrys chartarum^Chartomium PLUS: ^Chartomium PLUS: Trichoderma sp. ActinomyctesTrichoderma sp. ActinomyctesUrocladum sp. Gram Neg Bacteria Urocladum sp. Gram Neg Bacteria

Some Mold Toxic ProductsSome Mold Toxic Products

Fusarium producing DON Fusarium producing DON (deoxynivalenol); called vomitoxin(deoxynivalenol); called vomitoxin

OTA (ochratoxin A); leads to DNA breaksOTA (ochratoxin A); leads to DNA breaks

AFBAFB11 (Aflatoxin); leads to expoxide through (Aflatoxin); leads to expoxide through PP450450 System System

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“Hypersensitivity Pneumonitis Antigens” “Hypersensitivity Pneumonitis Antigens” Testing (IgG Antibodies) of limited prognostic Testing (IgG Antibodies) of limited prognostic Values, rather indicators of exposure. Values, rather indicators of exposure.

Perhaps better test is StachylsenPerhaps better test is StachylsenPerhaps better test is StachylsenPerhaps better test is Stachylsen(protein hemolysin) as indicator of exposure to (protein hemolysin) as indicator of exposure to

Stachybotrys chartarum, [not the same as Stachybotrys chartarum, [not the same as satratoxin H, a trichothecene]satratoxin H, a trichothecene]

Bacteria Genera Isolates from Building Materials:Bacteria Genera Isolates from Building Materials:Bacteria Genera Isolates from Building Materials:Bacteria Genera Isolates from Building Materials:AcinatobacterAcinatobacterBacillus NocardiaBacillus NocardiaClavibacter StreptomycesClavibacter StreptomycesCorybacterium ThermonosporiaCorybacterium ThermonosporiaFl B t iFl B t iFlavo BacteriumFlavo BacteriumMycobacteriaMycobacteria

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Remediation TasksRemediation Tasks

STOP Water IntrusionSTOP Water IntrusionSTOP Water IntrusionSTOP Water IntrusionIdentify Vulnerable PopulationsIdentify Vulnerable PopulationsDetermine Extent & Location of Determine Extent & Location of

Fungal ContaminationFungal Contamination(i.e. water and nutrients)(i.e. water and nutrients)

Id tif M i t D iId tif M i t D iIdentify Moisture DynamicIdentify Moisture DynamicControl source of moisture and nutrientsControl source of moisture and nutrients

after initial remediationafter initial remediation

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DECONTAMINATION OF MOLDDECONTAMINATION OF MOLD--11

(Work site example)(Work site example)

Internal Capsule in large room; wiped withInternal Capsule in large room; wiped with

fungicide immediatelyfungicide immediately

Air lock at both ends, 4 chambersAir lock at both ends, 4 chambers

HazHaz Mat SuitsMat Suits



Office items into Chamber #1Office items into Chamber #1

Move, and Fungicide items in #2Move, and Fungicide items in #2

Move, and HEPA vacuum in #3Move, and HEPA vacuum in #3

Move, Move, rewiperewipe in #4in #4

Out of airlock for inspection, possiblyOut of airlock for inspection, possibly

repassagerepassage

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DISCARD: Plants, Paper, insulation ceiling DISCARD: Plants, Paper, insulation ceiling tiles, insulationtiles, insulation

CLEAN: Drip pans, Office Machines, CLEAN: Drip pans, Office Machines, Carpets, Upholstered seatsCarpets, Upholstered seats

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Rye Grass StaggersRye Grass Staggers

mold contaminated feed to herd mold contaminated feed to herd animalsanimals


Mucous Membrane Irritation SyndromeMucous Membrane Irritation Syndrome(MMI):(MMI):

RhinorrheaRhinorrheaNasal CongestionNasal CongestionS Th tS Th tSore ThroatSore Throat

(?Inflammatory Cytokine based) (?Inflammatory Cytokine based)

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Any Moldy Questions?Any Moldy Questions?

Heavy lead is not always musicHeavy lead is not always music

Lead PoisoningLead Poisoning

Lead has no known biological functionLead has no known biological functionLead has no known biological function.Lead has no known biological function.

Lead PbLead Pb++++, competes with Ca, competes with Ca++++, Fe, Fe++++

It is cheap, useful, easy to mine, thereforeIt is cheap, useful, easy to mine, therefore

Lead is ubiquitousLead is ubiquitous-- in air, food, water, soil, ceilings in air, food, water, soil, ceilings tt

4848

etc.etc.

There is no consensus for safe lower limit for lead.There is no consensus for safe lower limit for lead.

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Number of new cases with blood lead levels Number of new cases with blood lead levels >> 25 25 g/g/dLdL that occurred among 100,000 employed that occurred among 100,000 employed adults 16adults 16--64 years old in 2005. Null category 64 years old in 2005. Null category

states did not report.states did not report.

Uses and Sources of Uses and Sources of LeadLead

P i t ( til 1970)P i t ( til 1970)Paint (until 1970)Paint (until 1970)

Household dust (via settlement of air Household dust (via settlement of air pollution, paint removal)pollution, paint removal)

Ceiling dustCeiling dust

OccupationalOccupational

5050

OccupationalOccupational

SolderSolder

Ceramic glazesCeramic glazes

Mines, smeltersMines, smelters

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More Uses and More Uses and Sources of Lead Sources of Lead

TV' C t itTV' C t itTV's, Computer monitorsTV's, Computer monitors

Batteries, Bullets SinkersBatteries, Bullets Sinkers

AviationAviation

XX--ray shieldsray shields

CrystalCrystal--ware (high levels in decanters)ware (high levels in decanters)

ExplosivesExplosives

5151

ExplosivesExplosives

NonNon--stick linings of pots (in the past)stick linings of pots (in the past)

Plastic colouring (wire, blinds)Plastic colouring (wire, blinds)

PewterPewter

Home Lead TestingHome Lead Testing

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Reduction of Lead Reduction of Lead hazards in the homehazards in the home

5353

Absorption of LeadAbsorption of Lead

5454

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Absorption of Absorption of LeadLead

Lead goes down iron or calcium absorption pathway in Lead goes down iron or calcium absorption pathway in GIT.GIT.GIT.GIT.

Children absorb lead well orally (~50%) cf adults poorly Children absorb lead well orally (~50%) cf adults poorly (~10%). Children also have more hand to mouth activity.(~10%). Children also have more hand to mouth activity.

Lead absorption is enhanced if diet is poor in iron or Lead absorption is enhanced if diet is poor in iron or calcium.calcium.

Pica is one of the worst risk factors.Pica is one of the worst risk factors.

S:S:\\LeadgpcLeadgpc\\BB Lead Poisoning.pptBB Lead Poisoning.ppt 5555

Lead can be inhaled.Lead can be inhaled.

[Tetraethyl lead can be absorbed via skin].[Tetraethyl lead can be absorbed via skin].

Contribution ofContribution ofSourcesSources

5656

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Distribution of Distribution of LeadLead

95% long bones.95% long bones.

Binds into matrix.Binds into matrix.

Released during Released during osteolysis.osteolysis.

5757

4% brain,liver, kidneys.4% brain,liver, kidneys.

1% blood.1% blood.

Crosses placenta, foetal Crosses placenta, foetal BBB is openBBB is open

Release of lead during Release of lead during osteolysisosteolysis

Pregnancy increases mobilization of lead fromPregnancy increases mobilization of lead fromPregnancy increases mobilization of lead from Pregnancy increases mobilization of lead from maternal skeletonmaternal skeletonGulson BL, Jameson CW, Mahaffey KR, Mizon KJ, Korsch MJ, Vimpani G.. J Lab Clin Med 1997a;130:51Gulson BL, Jameson CW, Mahaffey KR, Mizon KJ, Korsch MJ, Vimpani G.. J Lab Clin Med 1997a;130:51--62 62

Mobilization of lead from the skeleton during the postMobilization of lead from the skeleton during the post--natal period is larger than duringnatal period is larger than during ppregnancyregnancy..Gulson BL, Mahaffey KR, Jameson CW, Mizon KJ, Korsch MJ, Cameron MA, Eisman JA. J Lab Clin Med Gulson BL, Mahaffey KR, Jameson CW, Mizon KJ, Korsch MJ, Cameron MA, Eisman JA. J Lab Clin Med 1998a;131:3241998a;131:324--99

Lead is released in menopausal bone lossLead is released in menopausal bone loss

5858

Lead levels have second peak in middle ageLead levels have second peak in middle age-- more in more in men than women (NHANES 3).men than women (NHANES 3).

Lead follows calcium into and out of bone.Lead follows calcium into and out of bone.

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Lead movementLead movement

In childhood blood lead levels reflectIn childhood blood lead levels reflectIn childhood, blood lead levels reflect In childhood, blood lead levels reflect the environmental lead level ie the environmental lead level ie exogenousexogenous lead. Protection requires lead. Protection requires placing barriers between the child and placing barriers between the child and the lead.the lead.

5959

In adults, lead levels reflect the release In adults, lead levels reflect the release of of endogenousendogenous lead from bone, as well lead from bone, as well as the intake of as the intake of exogenousexogenous lead. lead. Protection requires prevention of Protection requires prevention of exposure plus preservation of boneexposure plus preservation of bone

Data from the US NHANES 3 study showing Data from the US NHANES 3 study showing the second peak of lead levels in adulthood. the second peak of lead levels in adulthood. Higher adult male levels reflect occupation Higher adult male levels reflect occupation and hobby. High risk occupations would be and hobby. High risk occupations would be

even higher. Women get a posteven higher. Women get a post--menopausal menopausal peak.peak.

6060

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Lead and Race. Data from the UIS Lead and Race. Data from the UIS NHANES 3 study showing differences NHANES 3 study showing differences

with race with race ––probably reflecting probably reflecting differences in accommodation and differences in accommodation and

occupationoccupation

6161

U.S. Lead Situation 1U.S. Lead Situation 1

1.1. 1978 Lead banned from paint1978 Lead banned from paint2.2. 1980's1980's-- Levels higher than AustraliaLevels higher than Australia2.2. 1980 s1980 s Levels higher than AustraliaLevels higher than Australia3.3. Late 1980's Removal of lead from gasolineLate 1980's Removal of lead from gasoline4.4. 1980's Universal questionnaire screening1980's Universal questionnaire screening5.5. 1991 Universal blood testing1991 Universal blood testing6.6. 1990's Public housing program1990's Public housing program7.7. 1990's Private housing program1990's Private housing program88 1990's Massive EPA environmental program1990's Massive EPA environmental program

6262

8.8. 1990's Massive EPA environmental program1990's Massive EPA environmental program

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HealthHealthHealth Health Effects of Effects of

LeadLeadConcentration Concentration

6363

relatedrelated

IQ/ delinquency IQ/ delinquency related to total related to total dosage in childhooddosage in childhood

Symptoms from lead are rare!Symptoms from lead are rare!

6464

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Lead and Lead and NeurodevelopmentNeurodevelopment

Each 0.48 µmol/l(10µg/dl)Each 0.48 µmol/l(10µg/dl) in children.in children.= 4 to 7 IQ points (US Acad. Pediatrics).= 4 to 7 IQ points (US Acad. Pediatrics). 4 to 7 IQ points (US Acad. Pediatrics). 4 to 7 IQ points (US Acad. Pediatrics).Industry/ Industry/ Australian Australian government consensusgovernment consensusof 3of 3--55 IQ points.IQ points.Effects on behaviour are FAR WORSE.Effects on behaviour are FAR WORSE.Delinquency rates are 8 times higher in the top 30% Delinquency rates are 8 times higher in the top 30% of bone lead. Needleman 1996.of bone lead. Needleman 1996.Needleman, Herbert L. et al, "Bone Lead Levels and Delinquent Behavior," JOURNAL OF THE AMERICAN Needleman, Herbert L. et al, "Bone Lead Levels and Delinquent Behavior," JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Vol. 275, No. 5 (February 7, 1996), pgs.363MEDICAL ASSOCIATION Vol. 275, No. 5 (February 7, 1996), pgs.363--369.369.

6565

Measurable adverse behaviour changes in 2 year Measurable adverse behaviour changes in 2 year olds Mendelsohn 1999. olds Mendelsohn 1999. Alan L. Mendelsohn, Benard P. Dreyer, Arthur H. Fierman, Alan L. Mendelsohn, Benard P. Dreyer, Arthur H. Fierman, Carolyn M. Rosen, Lori A. Legano, Hillary A. Kruger, Sylvia W. Lim, and Cheryl D. Courtlandt "Carolyn M. Rosen, Lori A. Legano, Hillary A. Kruger, Sylvia W. Lim, and Cheryl D. Courtlandt "LowLow--Level Level Lead Exposure and Behavior in Early Childhood“Lead Exposure and Behavior in Early Childhood“ PPediatrics 1998; 101: e10 ediatrics 1998; 101: e10

Lead and IQLead and IQ

6666

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Lead and the ElderlyLead and the Elderly

Risk of dementia increases with lead Risk of dementia increases with lead b db dburdenburden

Risk of accidental lead ingestionRisk of accidental lead ingestion

6767

Unresolved QuestionsUnresolved Questions

How much does lead contribute to How much does lead contribute to iti d li d Al h i ’iti d li d Al h i ’cognitive decline and Alzheimer’s cognitive decline and Alzheimer’s

disease?disease?

Do bone preserving therapies or calcium Do bone preserving therapies or calcium supplements reduce cognitive decline?supplements reduce cognitive decline?

Is lead a modifiable risk factor forIs lead a modifiable risk factor for

6868

Is lead a modifiable risk factor for Is lead a modifiable risk factor for dementia?dementia?

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Childhood Risk FactorChildhood Risk FactorQuestionnaireQuestionnaire

Does your child….

Have a brother or sister, housemate or No playmate with an elevated blood lead level? Yes

Sometimes eat non-food items such as soil or paint?

No Yes

Have any of the following conditions sometimes associated with lead poisoning, eg iron deficiency anaemia, behaviour problem, learning problem or developmental delay?

No Yes

32 wd toxic exposures garman.ppt exposures_garman.pdf · 11/6/2008 1 environmental challanges...

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