HEPM 1HEPM 1Introduction to HygieneIntroduction to Hygiene

(seminar)

Milena ČernáMilena Černá

Institute of General HygieneInstitute of General Hygiene

What is HEPM?

Hygiene, epidemiology and preventive medicine

Not only diagnosis and therapy, but also preventive approaches, above all primary prevention, are integral parts of medicine.

Primary prevention

To remove potential health hazards from the environment prior to population exposure and to support protective lifestyle

Health status determinants(EXTERNAL)(EXTERNAL)

Lifestyle (50-60 %) (smoking, inadequate nutrition, alcohol, drugs and

medicament abuse, low physical activity, sexual behavior, high level of psychosocial stress)

Environment (20 %) (chemical, physical, biological factors, air, water, soil

pollution, food chain contamination, etc)

Health care (20 %) (insufficient prevention, late diagnostics, inadequate

treatment, pure compliance)

Health status determinants (cont.)

InternalInternal

Individual susceptibility Individual susceptibility (heritability, health (heritability, health status, agestatus, age, gender, gender etc.) etc.)

(Environment – Gene- interaction)(Environment – Gene- interaction)

Socioeconomical status Socioeconomical status (education, income (education, income etcetc..))

Optimal healthOptimal healthA sustained state of optimal physical, A sustained state of optimal physical,

neuro/cognitive, psychological and social well neuro/cognitive, psychological and social well beingbeing (definition of WHO) (definition of WHO)

Hygiene Hygiene (Hygiea = goddess of health)(Hygiea = goddess of health)

Science studying the iScience studying the influence of environmental nfluence of environmental

factorfactorss on human health on human health

Environmental Environmental health health (Environmental m(Environmental medicineedicine))

Knowledge of interaction of human body with Knowledge of interaction of human body with the environment by means of inherited and the environment by means of inherited and built-in biologic mechanisms and systemsbuilt-in biologic mechanisms and systems

What is environmental health?What is environmental health?

Environmental health comprises those aspects of human health and disease that are determined by factors in the environment. It also refers to the theory and practice of assessing and controlling factors in the environment that can potentially affect health.As used by WHO/Europe, environmental health includes both the direct pathological effects of chemicals, radiation and some biological agents, and the effects (often indirect) on health and wellbeing of the broad physical, psychological, social and aesthetic environment.

(Based on Environment and Health, the European Charter and Commentary, Frankfurt, 1989)

10 greatest global health risks(WHO, 2002)

• Being underweight • Unsafe sex• Iron deficiency• Indoor smoke from solid fuels• Unsafe water, sanitation, and

hygiene• High blood pressure• Tobacco consumption• Alcohol consumption• High cholesterol• Obesity

Developing countries

Developed countries

WHO and healthy environmentWHO and healthy environment-developing countries-developing countries

• Worldwide, 13 million deaths could be prevented every

year by making our environments healthier. • In children under the age of five, one third of all disease is

caused by the environmental factors such as unsafe water and air pollution.

• Every year, the lives of four million children under 5 years – mostly in developing countries – could be saved by preventing environmental risks such as unsafe water and polluted air.

• In developing countries, the main environmentally caused In developing countries, the main environmentally caused diseases are diarrheal disease, lower respiratory infections, diseases are diarrheal disease, lower respiratory infections, unintentional injuries, and malaria.unintentional injuries, and malaria.

• Better environmental management could prevent 40% of Better environmental management could prevent 40% of deaths from malaria, 41% of deaths from lower respiratory deaths from malaria, 41% of deaths from lower respiratory infections, and 94% of deaths from diarrhoeal disease infections, and 94% of deaths from diarrhoeal disease

WHO and healthy environment WHO and healthy environment – developed countries– developed countries

• In developed countries, healthier environments could In developed countries, healthier environments could significantly reduce the incidence of cancers, cardiovascular significantly reduce the incidence of cancers, cardiovascular diseases, asthma, lower respiratory infections, diseases, asthma, lower respiratory infections, musculoskeletal diseases, road traffic injuries, poisonings, musculoskeletal diseases, road traffic injuries, poisonings, and drowningsand drownings..

• Environmental factors influence 85 out of the 102 categories Environmental factors influence 85 out of the 102 categories of diseases and injuries listed in of diseases and injuries listed in The world health report.The world health report.

• Much of this death, illness and disability could be prevented Much of this death, illness and disability could be prevented through well targeted interventions such as promoting safe through well targeted interventions such as promoting safe household water storage, better hygiene measures and the household water storage, better hygiene measures and the use of cleaner and safer fuels.use of cleaner and safer fuels.

• Other interventions that can make environments healthier Other interventions that can make environments healthier include: increasing the safety of buildings; promoting safe, include: increasing the safety of buildings; promoting safe, careful use and management of toxic substances at home careful use and management of toxic substances at home and in the workplace; and better water resource and in the workplace; and better water resource management.management.

Environmental factors (stressors)

• Physical factors (climate, climate, indoor indoor microclimate, microclimate, ionizing and non-ionizing radiation, solar ionizing and non-ionizing radiation, solar radiation, noise, vibration)radiation, noise, vibration)

• Chemical factorsChemical factors – acute, chronic, specific – acute, chronic, specific effects, delayed effects, transplacental exposureeffects, delayed effects, transplacental exposure

• Biological factorsBiological factors - microorganisms, fungies, - microorganisms, fungies, cyanobacteriae, algae and their toxins, plants, cyanobacteriae, algae and their toxins, plants, insect, animals, human beinginsect, animals, human being

Environmental mediaEnvironmental media

• Outdoor and indoor airOutdoor and indoor air• Water – drinking water, bathing watersWater – drinking water, bathing waters, waste , waste

waterswaters• Water sedimentWater sediment• SoilSoil• BiotaBiota• Food chains - Food chains -

Environmental stressors

Generaly, the majority of the environmental stressor can have both positive and negative effects depending on the dose and the ability of individuum to compensate negative effects (adaptation, genetic background etc.)

You will receive more information in the next years of your study (risk assessment, health impact assessment, genetic polymorphism etc.)

Environmental epidemiologyEnvironmental epidemiology

Study of relationship between environmental stressors and population health

• Environmental indicators-Environmental indicators- simplified compounds in environmental simplified compounds in environmental

media characterized the levels of more media characterized the levels of more complicated komplex environmental complicated komplex environmental pollutionpollution

• Health indicators – demographic dataHealth indicators – demographic data (mortality, morbidity)(mortality, morbidity)

Physical factors in the environment

Solar radiation: Positive: vitamin D production, well-beingNegative: increase of skin cancer, ageing of skin,

cataract… Noise: Damage of hearing (occupational exposure, noisy

disco)Systemic effect (general population) – disorder of

vegetative system – increase of blood pressure, disorder of concentration during the work or study, sleeping problems, increased risks of neuroses

Physical factors in the environment (cont.)

VibrationMostly at occupational exposure (e.g. pneumatic

drill), but also in the ordinary living conditions (kinetosis due to transport – seasickness).

Ionizing radiationDisasters (nuclear power plants)Occupational exposure (radiotherapy, radiodg)Exposure of patientsNatural exposure from cosmosEffects: deterministic (dose-dependent with

threshold stochastic (probability is increasing after

the first dose – carcinogenicity)

Chemical stressorsChemical stressors

Environmental chemical contaminants represent large-scale adverse health effects dependent on toxicological characteristics of appropriate compounds, dose (amount) and biotransformation (detoxication) capacity of human body.

Paracelsus 15. – 16. Century

„Dosis facit venenum

Chemical stressorsChemical stressors (cont.) (cont.)

Acute - subacute – chronic intoxicationsAcute - subacute – chronic intoxications

Simple or repeated exposureSimple or repeated exposure

Adverse effects with tAdverse effects with thresholdhreshold

Delayed effects (mutagenic, carcinogenic) without Delayed effects (mutagenic, carcinogenic) without thresholsthreshols

Organ-specific effects: Organ-specific effects: kidney or liver damage, kidney or liver damage,

Embryotoxicity, damage of Embryotoxicity, damage of fetal development, fetal development, endocrine system disruption, immunotoxicityendocrine system disruption, immunotoxicity

Source of exposure:Source of exposure:

Occupation – polluted air, water, food - hobbiesOccupation – polluted air, water, food - hobbies

Adverse health effects of environmental Adverse health effects of environmental factorsfactors

• Delayed effects (mDelayed effects (mutagenic, carcinogenicutagenic, carcinogenic))• Allergenic (pollen, household dust, mites, Allergenic (pollen, household dust, mites,

household cleaning compounds, etc…..)household cleaning compounds, etc…..)• Reproduction disorders (polycyclic aromatic Reproduction disorders (polycyclic aromatic

hydrocarbons - PAHs, persistent organic hydrocarbons - PAHs, persistent organic chemicals - POPs)chemicals - POPs)

• Developmental toxicity (Pb, polychlorinated Developmental toxicity (Pb, polychlorinated biphenyls – PCBs, dioxins etc.)biphenyls – PCBs, dioxins etc.)

• Endocrine disrupting chemicals (POPs, PAU, Cd, Endocrine disrupting chemicals (POPs, PAU, Cd, zearalenon - zearalenon - mmycotoxins)ycotoxins)

• Neurotoxicity (Hg, As, Pb, PCB, dioxins)Neurotoxicity (Hg, As, Pb, PCB, dioxins)

Fate of chemicals in the Fate of chemicals in the environmentenvironment

Source: Source: industry, traffic, heating, agricultureindustry, traffic, heating, agriculture

Polluted medium:Polluted medium: preferentially air, preferentially air, surface or surface or waste waterswaste waters

Pollutants in the air can interact and generate new Pollutants in the air can interact and generate new structures, they move to sediments, soil, structures, they move to sediments, soil,

Food chain:Food chain: soil, water, air – vegetation – soil, water, air – vegetation – herbivorous animals – omnivorous animals herbivorous animals – omnivorous animals

- - humanhuman

Sources of air pollution

Environmental media

Types of problems susceptible to study Types of problems susceptible to study

and evaluationand evaluation by environmental by environmental epidemiologyepidemiology

• Air pollution, outdoor and indoorAir pollution, outdoor and indoor• Occupational exposureOccupational exposure• Surface and ground water pollution (consumers, Surface and ground water pollution (consumers,

recreation)recreation)• Use of pesticides in agriculture, food contaminationUse of pesticides in agriculture, food contamination• Health effect of radiation (ionizing, nonionizing)Health effect of radiation (ionizing, nonionizing)• Effects of cigarette smoking, interaction with Effects of cigarette smoking, interaction with

occupational or environmental exposureoccupational or environmental exposure• Heavy metals and trace chemicals in the Heavy metals and trace chemicals in the

environmentenvironment• Health impact of urbanizationHealth impact of urbanization (megapolis) (megapolis)• Health effects of traffic, motor vehicles, injuriesHealth effects of traffic, motor vehicles, injuries

Endocrine disrupting chemicals (EDC)Endocrine disrupting chemicals (EDC) as environmental pollutants and their as environmental pollutants and their

health effectshealth effects

DefinitionDefinition

Endocrine disruptors are environmental Endocrine disruptors are environmental chemicals that alter gene activity during chemicals that alter gene activity during sensitive developmental periods when sensitive developmental periods when cells differentiation is occurring, and cells differentiation is occurring, and irreversibly disrupt the functioning of irreversibly disrupt the functioning of disrupt cells.disrupt cells.

Potential health effects from Potential health effects from the population point of viewthe population point of view

Incidence of breast carcinoma has been increasing Incidence of breast carcinoma has been increasing about 1 % yearly (this type of carcinoma is usually about 1 % yearly (this type of carcinoma is usually hormonally dependent)hormonally dependent)

Iincreasing tendencies are observedIincreasing tendencies are observed in in the incidence the incidence of:of:

endometriosisendometriosis

cryptorchidismcryptorchidism

prostate carcinomaprostate carcinoma

testicular cancertesticular cancer

hypospadiahypospadia

Globální transportGlobální transport

What compounds belong to EDC?What compounds belong to EDC?

DDT and similar obsolete pesticidesPolychlorinated biphenylesDioxinsFlame retardantsPhthalates

Long-term health effects in general population

ChildrenChildren are the most sensitive and vulnerable are the most sensitive and vulnerable population group (ED-compounds can cross the population group (ED-compounds can cross the placenta and are present in human milk)placenta and are present in human milk)

NeurotoxicityNeurotoxicity

Reproduction disordersReproduction disorders

HypothyreosisHypothyreosis

Worsening of psychomotoric development of childrenWorsening of psychomotoric development of children

However, the adverse health changes are mostly However, the adverse health changes are mostly transitional.transitional.

Global regulation of persistent Global regulation of persistent chlorinated organic compoundschlorinated organic compounds

Stockholm convention May 22, 2001Stockholm convention May 22, 2001AnnexAnnex ChemicalsChemicals• EliminationElimination: : Aldrin (pesticide), Chlordane Aldrin (pesticide), Chlordane

(pesticide/termiticide), Dieldrin (pesticide), (pesticide/termiticide), Dieldrin (pesticide), Endrin(pesticide), Heptachlor (pesticide/termiticide), Endrin(pesticide), Heptachlor (pesticide/termiticide), Hexachlorobenzene (pesticide), Mirex(pesticide), Hexachlorobenzene (pesticide), Mirex(pesticide), Toxaphene(pesticide), Polychlorinated biphenyls Toxaphene(pesticide), Polychlorinated biphenyls (industrial chemical)(industrial chemical)

• RestrictionRestriction: : DDTDDT (disease vector control, intermediate (disease vector control, intermediate in production of dicofol) in production of dicofol)

• UnintentionalUnintentional:: Production Polychlorinated dibezo-p- Production Polychlorinated dibezo-p-dioxins and dibenzofurans, Hexachlorobenzene, dioxins and dibenzofurans, Hexachlorobenzene, Polychlorinated biphenylsPolychlorinated biphenyls

International Society for Environmental Epidemiology(ISEE)

WHO/Europe

European Environmental Protection Agency

APHEIS: Air pollution and Health: a European Informative System

EFSA (European Food Safety Agency

Environmental Health Indicator System

AIRNET: http://airnet.iras.uu.nl

International environmental International environmental health (USA)health (USA)

U.S. EPA (Environmental Protection Agency)U.S. EPA (Environmental Protection Agency)

ATSDR (Agency for Toxic Substances and Disease ATSDR (Agency for Toxic Substances and Disease Registry)Registry)

(responsible for public health assessment of hazardous waste (responsible for public health assessment of hazardous waste sites, specific hazardous substances, health surveillance and sites, specific hazardous substances, health surveillance and registries, applied research in public health assessment, registries, applied research in public health assessment, information development and dissemination, education and information development and dissemination, education and training concerning hazardous substances)training concerning hazardous substances)

International Environmental Health Subcommittee International Environmental Health Subcommittee coordinates:coordinates:

ATSDR, NCEH (Nat. Center Environ. Hlth), NIOSH (Nat. Inst. ATSDR, NCEH (Nat. Center Environ. Hlth), NIOSH (Nat. Inst. Occup. Safety and Hlth), CDC (Centers for Disease Control and Occup. Safety and Hlth), CDC (Centers for Disease Control and Prevention) NIEHS (Nat. Inst. Environ. Hlth Sci), NIH (Nat. Inst. Prevention) NIEHS (Nat. Inst. Environ. Hlth Sci), NIH (Nat. Inst. Hlth), FDA, EPA, OSHA (Occ. Safety and Hlth Administration)Hlth), FDA, EPA, OSHA (Occ. Safety and Hlth Administration)

Prevention

Primary prevention To remove potential health hazards from the

environment prior to population exposure and to support protective lifestyle

Secondary prevention Use of biomarkers of exposure/effects with the intention

to find early signal of exposure or reversible effects and to avoid irreversible changes

Tertiary prevention Measures aiming at preventing complications that may

appear in the course of the disease

Environmental Health Projects

EU: Action plan on Environment and Health

National Environmental Health Action Plans (NEHAP)

Local Environmental Health Action Plans (LEHAP)

EC Strategy on Health and Environment:

(Outdoor and indoor air pollutants quality, Noise, Indoor environment and housing conditions, Water quality contamination, Elmg fields and radiation, Chemical

exposures)

http:europa.eu.int/comm/health/

Health protection, health Health protection, health promotion toolspromotion tools

• Repressive measures: Repressive measures: Legislation (acts, regulations, limit values, Legislation (acts, regulations, limit values,

biologically important values (MAC, PEL, ADI, TDI, biologically important values (MAC, PEL, ADI, TDI, PTDI etc.)PTDI etc.)

• Recommendable (advisory) measures:Recommendable (advisory) measures: proper lifestyle, optimal nutrition, right behavior in proper lifestyle, optimal nutrition, right behavior in

problematic environmental situations, support of problematic environmental situations, support of breastfeeding, physical activity etc. breastfeeding, physical activity etc.

Risk communication with public Risk communication with public Explanation the problem, its importance and Explanation the problem, its importance and

necessary od possible preventive measures. necessary od possible preventive measures. Vertical and horizontal feedback.Vertical and horizontal feedback.

Environmental health in the 21st century

To prevent diseases, not only to cure them

Better understanding of human risk through integration of the scientific disciplines:

Toxicology, epidemiology, genetics, public health

Information (data) – understanding (knowledge)

To control the right things to the right levels

Toxicogenomics, genomics (environmental effects on genes and gene products), other - omics

Biomarkers at the molecular level (molecular dosimetry, molecular epidemiology)

Environmental effects on cell function, communication, regulation