GRADE: Assessing the quality of evidence in environmental and occupational health

There is high demand in environmental health for adoption of a structured process that evaluates and integrates evidence while making decisions and recommendations transparent. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework holds promise to address this demand. For over a decade, GRADE has been applied successfully to areas of clinical medicine, public health, and health policy, but experience with GRADE in environmental and occupational health is just beginning. Environmental and occupational health questions focus on understanding whether an exposure is a potential health hazard or risk, assessing the exposure to understand the extent and magnitude of risk, and exploring interventions to mitigate exposure or risk. Although GRADE offers many advantages, including its flexibility and methodological rigor, there are features of the different sources of evidence used in environmental and occupational health that will require further consideration to assess the need for method refinement. An issue that requires particular attention is the evaluation and integration of evidence from human, animal, in vitro, and in silico (computer modeling) studies when determining whether an environmental factor represents a potential health hazard or risk. Assessment of the hazard of exposures can produce analyses for use in the GRADE evidence-to-decision (EtD) framework to inform risk-management decisions about removing harmful exposures or mitigating risks. The EtD framework allows for grading the strength of the recommendations based on judgments of the certainty in the evidence (also known as quality of the evidence), as well as other factors that inform recommendations such as social values and preferences, resource implications, and benefits. GRADE represents an untapped opportunity for environmental and occupational health to make evidence-based recommendations in a systematic and transparent manner. The objectives of this article are to provide an overview of GRADE, discuss GRADE's applicability to environmental health, and identify priority areas for method assessment and development.     

Indoor radon in a Spanish region with different gamma exposure levels

In the beginning of 1990s within the framework of a national radon survey of more than 1500 points, radon measurements were performed in more than 100 houses located in Galicia region, in the Northwest area of Spain. The houses were randomly selected only bearing in mind general geological aspects of the region. Subsequently, a nationwide project called MARNA dealt with external gamma radiation measurements in order to draw a Spanish natural radiation map. The comparison in Galicia between these estimations and the indoor radon levels previously obtained showed good agreement. With the purpose of getting a confirmation of this relationship and also of creating a radon map of the zone, a new set of measurements were carried out in 2005. A total of 300 external gamma radiation measurements were carried out as well as 300 measurements of (226)Ra, (232)Th and (40)K content in soil. Concerning radon, 300 1-m-depth radon measurements in soil were performed, and indoor radon concentration was determined in a total of 600 dwellings. Radon content in soil gave more accurate indoor radon predictions than external gamma radiation or (226)Ra concentration in soil.     

Assessment of health risk levels associated with terrestrial gamma radiation dose rates in Nigeria

A decree on radiation safety and protection have been signed by the Federal Government of Nigeria that established a regulatory body to control the importation, application, transportation and disposal of radioactive materials in the environment. The fundamental function of the body is embodied on radiation protection of the country's population and the environment. However, the protection and assessment of any radiation pollution in the environment to a large extent is based on the knowledge of the baseline of radiation dose rate levels due to natural radionuclides. This study assesses the risks associated with terrestrial gamma radiation dose rate levels in some cities across the major geological formations of the country. Results showed that in the Northern region the number of individuals at risk of incurring cancer ranged between 0.25 and 3.25 yr with an average value of 1.46+/-0.45, while in the southwestern region it ranged between 0.76 and 5.50 yr(-1) with a mean value of 1.66+/-0.63 and in the southeastern region it was between 0.17 and 0.89 yr(-1) with a mean value of 0.35+/-0.14. Assuming uniform exposure for the entire population of 98.5 million, it has been estimated that about 160 individuals annually are at risk of incurring cancer due to exposure to terrestrial gamma radiation.     

Using air pollution based community clusters to explore air pollution health effects in children

To study respiratory health effects of long-term exposure to ambient air pollutant mixture, we observed 7058 school children 5-16 years of age living in the four Chinese cities of Lanzhou, Chongqing, Wuhan, and Guangzhou. These children were enrolled from elementary schools located in eight districts, one urban district and one suburban district in each of the above cities. Ambient levels of PM(2.5), PM(10-2.5), total suspended particles (TSP), SO(2), and NO(x) were measured in these districts from 1993 to 1996. Based on a cluster analysis of arithmetic mean concentrations of PM(2.5), PM(10-2.5), (TSP-PM(10)), SO(2), and NO(x), we classified these children into four ordinal categories of exposure to ambient air pollutant mixtures. We tested for exposure-response relationships using logistic regression models, controlling for relevant covariates. We observed monotonic, positive relationships of exposure to the pollutant mixture with prevalence rates of cough with phlegm and wheeze. Other outcomes were not associated with the exposure in a monotonic exposure-response pattern. Even so, odds ratios for cough, phlegm, bronchitis, and asthma in the higher exposure district clusters were all higher than in the lowest exposure district cluster. We found evidence that exposure to the pollutant mixtures had adverse effects on children living in the four Chinese cities.     

The significance of different health institutions and their respective contributions of active pharmaceutical ingredients to wastewater

Active pharmaceutical ingredients (APIs) have been frequently found in the environment. It is, however, still not quite clear who is mainly responsible for API emissions. Hospitals have been considered to be the main contributing point sources for wastewater (WW) discharge of APIs. However, recent studies have shown that the contribution of hospitals to the input of APIs into the aquatic environment is quite low. Due to demographic change and the increase of psychiatric diseases, health institutions (HIs) such as psychiatric hospitals and nursing homes are likely to be important sources as well, but no data is available in this respect. This study aims to assess the impact of HIs and to provide a methodology to measure their respective contributions. Drawing on pharmaceutical consumption data for the years 2010, 2011, and 2012, this study identified API usage patterns for a psychiatric hospital (146 beds), a nursing home (286 inhabitants), and a general hospital (741 beds), the latter of which comprises three separate locations. All the HIs are located in two sub-regions of a county district with about 400,000 citizens in southwestern Germany. A selection of neurological drugs was quantified in the sewer of these facilities to evaluate the correlation between consumption and emission. The API contribution of HIs was assessed by comparing the specific consumption in the facilities with the consumption in households, expressed as the emission potential (I_EP). The study shows that the usage patterns of APIs in the psychiatric hospital and the nursing home were different from the general hospital. Neurological drugs such as anticonvulsants, psycholeptics, and psychoanaleptics were mainly consumed in the psychiatric hospital and the nursing home (74% and 65%, respectively). Predicted and average measured concentrations in the effluent of the investigated HIs differed mostly by less than one order of magnitude. Therefore, the consumption-based approach is a useful method to assess usage patterns of APIs in HIs and to predict their respective contributions to WW. The national contribution of HIs on total WW discharge of APIs compared to households was very low. Only the results for the sedative clomethiazole in general hospitals as well as the antidepressant moclobemide and the antipsychotic quetiapine for the nursing homes were found to deserve some attention. The regional comparison showed that in sub-regions with a comparably higher density of HIs, the allocated facilities could be seen as point sources emitting particular APIs. However, in general, the bulk of the consumed pharmaceuticals to WW discharge has to be attributed to households.     

Practical consequences of the assessment of different energy health risks

Public authorities must make decisions about energy, and the risks of alternative strategies need to be calculated including health and environmental costs. Information from various sources must be organized into a logical framework for comparing impacts. This must include the widest practicable range of health and environmental damage — public-health impact of pollution, role of accidents, disease and hazardous materials in the workplace, and odds for catastrophes. It must put each part of the energy cycle into perspective-giving particular attention to uncertainties in knowledge - to convey what is known, what is uncertain, and the importance of each factor in the overall picture. This paper gives examples of the use of health-impact assessment by decisionmakers: (1) comparative risk assessment of the health effects of coal and nuclear fuel cycles used in nuclear power plant siting and licensing hearings, and (2) health risks of acid deposition and other air-transported pollutants, carried out as part of an assessment for the U.S. Congress Office of Technology Assessment.     

Tritium levels in Chinese cabbage and radish plants acutely exposed to HTO vapor at different growth stages

To simulate an acute exposure of Chinese cabbage and radish plants to airborne HTO, the potted plants were exposed to HTO vapor under semi-outdoor conditions for 1h at different times from the early to late growth stages. The plants were grown outdoors and the plant tritium was measured at the end of an exposure (h(0)) and at harvest. The leaf tissue free water tritium (TFWT) concentrations at h(0) were considerably lower than estimated equilibrium concentrations. In the leaves of Chinese cabbage, the exposure at the earlier growth stage generally ended with a higher TFWT concentration. Such a tendency was not apparent either in the leaves or roots of radish. On the other hand, the earlier stage exposure gave rise to lower TFWT concentrations at the harvest of both crops. For the OBT (organically bound tritium), however, the same occurred only in the Chinese cabbage leaves. During the period between the exposure and harvest, the TFWT concentrations reduced by factors of up to 1.1 x 10(6) for the Chinese cabbage leaves and 1.3 x 10(4) for the radish roots. Based on the activity ratios of OBT to TFWT at harvest, it is estimated that OBT mostly contributes much more to the ingestion dose than TFWT does.     

Regional consequences of the way land users respond to future water availability in Murcia, Spain

Agricultural development in the Murcia autonomous region, Spain, has led to overexploitation of groundwater resources, and climate change will further increase pressures. Policy options to tackle the current unsustainable situation include the development of inter-basin water transfer (IBWT) schemes from wetter regions in the north and the introduction of taxation to further control groundwater abstraction. Under these scenarios, farmers with current access to water could face higher water cost, whereas farmers in areas where water was previously not available could see first time availability of water resources. In this paper, we combine discrete choice-based interviews with farmers in the Torrealvilla catchment, in which they indicate how they would adapt their land use under different scenarios, with an input–output model to assess the aggregate effects of individual land use decisions on the economy and water consumption of the Murcia region. The paper presents steps taken in the development of an input–output table for Murcia, including disaggregation of the agricultural sector, accounting for sector water use and consideration of back- and forward linkages. We conclude that appropriate taxation can lead to better water use efficiency, but that this is delicate as relatively small changes in prices of agricultural products can have significant impacts on land use and water consumption. Although new IBWT schemes would enable water to be used more efficiently, they would considerably increase regional water consumption and the regional economy’s dependence on water. As this is not sustainable under future climate change, water saving development pathways need to be explored.     

Assessment of current exposure levels in different population groups of the Kola Peninsula

Activity concentrations of 137Cs and 90Sr in samples of vegetation and natural food products collected in the Kola Peninsula in 1998 and 1999 indicate a very slow decrease in contamination levels during the last decade, mainly due to the physical decay of the radionuclides. The activity concentrations of 137Cs in reindeer meat decreased with a half-life of about 9 years. 137Cs in lichen, moss and fungi is significantly higher than in natural vegetation (grasses) and agricultural plants (potatoes). The activity concentrations of 137Cs in reindeer meat were two orders of magnitude higher than those in locally produced beef and pork. Consumption of reindeer meat, fish, mushrooms and berries constituted the main contribution to the internal dose from 137Cs and 90Sr for reindeer-breeders in the Lovozero area. The estimated committed doses due to 137Cs intake in this group were about 10 microSv per month in summer 1998 and 15 microSv per month in winter, 1999. There was good agreement between internal dose estimates based on intake assessment and whole body measurements. The population of Umba settlement, which is not involved in reindeer breeding, received individual committed doses due to 137Cs intake of about 0.5 microSv per month, about a factor of 20 less than the reindeer-breeders in Lovozero. In this case, the main contribution to the internal dose of the general population came from consumption the of 137Cs in mushrooms and forest berries. The contribution of 90Sr to the internal dose varied from 1% to 5% in the different population groups studied.     

Using the Community Multiscale Air Quality (CMAQ) model to estimate public health impacts of PM2.5 from individual power plants

We estimated PM_2.5-related public health impacts/ton emitted of primary PM_2.5, SO₂, and NO_x for a set of power plants in the Mid-Atlantic and Lower Great Lakes regions of the United States, selected to include varying emission profiles and broad geographic representation. We then developed a regression model explaining variability in impacts per ton emitted using the population distributions around each plant. We linked outputs from the Community Multiscale Air Quality (CMAQ) model v 4.7.1 with census data and concentration–response functions for PM_2.5-related mortality, and monetized health estimates using the value-of-statistical-life. The median impacts for the final set of plants were $130,000/ton for primary PM_2.5 (range: $22,000–230,000), $28,000/ton for SO₂ (range: $19,000–33,000), and $16,000/ton for NOx (range: $7100–26,000). Impacts of NO_x were a median of 34% (range: 20%–75%) from ammonium nitrate and 66% (range: 25%–79%) from ammonium sulfate. The latter pathway is likely from NO_x enhancing atmospheric oxidative capacity and amplifying sulfate formation, and is often excluded. Our regression models explained most of the variation in impact/ton estimates using basic population covariates, and can aid in estimating impacts averted from interventions such as pollution controls, alternative energy installations, or demand-side management.     

Organochlorine pesticide and polychlorinated biphenyl residues in feathers of birds from different trophic levels of South-West Iran

Persistent organochlorine pesticides (OCPs), such as dichlorodiphenyltrichloroethane (DDT) and its metabolites, hexachlorobenzene (HCB), alpha, beta and gamma-hexachlorocyclohexane (HCH) isomers, together with polychlorinated biphenyl (PCB) congeners (IUPAC Nos. 28, 52, 101, 138, 153 and 180), were determined in tail feathers from 37 birds belonging to 18 species, all originating from the South-West of Iran (Khuzestan, coast of the Persian Gulf). This is the first report on organochlorine contaminants in feathers from museum collections and it is an indication of the concentrations of OCPs and PCBs in the past (1991-1996). Median concentrations of HCHs, DDTs, PCBs and HCB were 22, 14, 11 and 10 ng/g feather, respectively. Significant correlations (p<0.05) were calculated between OCPs (except HCB) and PCBs in the bird feathers. p,p'-DDE and gamma-HCH were the most abundant OCPs, while CB 180, CB 138 and CB 101 were the predominant PCB congeners in almost all species. Significant differences (p<0.05) in the mean concentrations of DDTs and PCBs were detected among species grouped according to their feeding habits. Levels of DDTs and PCBs were highest in the carnivorous species and lowest in the herbivorous species. Levels of OCPs and PCBs in feathers of bids in the 1990s were generally below the thresholds reported to affect reproduction.     

Education in environmental health of health care professionals: What needs to be done?

BackgroundHealth professionals are key actors in environmental health. Taking on this role requires a certain degree of competence. That is the reason why education in environmental health of health care professionals became a major concern at international level, notably at WHO level. However, in the European Union only the individual Member States are responsible for organizing education and no official body seems to have started outlining recommendations on how to set up this kind of training.ObjectivesWe set out to draw up some propositions for training in environmental health on the basis of the practice of educational institutions involved in training health care professionals.MethodsA survey was conducted in 934 educational institutions involved in training health care professionals in 11 European countries and in Canada.ResultsOur data reveal that, whereas there are many establishments — nearly half of those that replied — engaged in educating health care professionals in environmental health, they do so in a great variety of ways, whether in terms of objectives, content, the number of teaching hours, or their target groups. Moreover, there is only limited evaluation of this training, which makes the question of recognition a very difficult one.ConclusionsNumerous difficulties have been raised in relation to education in environmental health, both by trainers and trainees. Some solutions to these difficulties are suggested but the need of official guidelines keeps going.     

Histomorphological structure of the liver in roach (Rutilus rutilus) and pike (Esox lucius) from lakes with different levels of anthropogenic impact

Using histological techniques, changes in histomorphological characteristics of the liver were revealed in two fish species from lakes with different levels of anthropogenic impact. The most significant changes in the liver of roach from Kostomukshskoe Lake (used as a tailing dump of the Kostomuksha Mining and Ore-processing Plant) included initial stages of parenchymal protein dystrophy and, to a lesser extent, fatty dystrophy; in pike, fatty liver dystrophy prevailed. Compared to roach, pike proved to be more sensitive to ecological conditions in Kostomukshskoe lake, including increased water mineralization. In both fish species from Koivas Lake (20 km from the pollution source), only the initial stages of local dystrophic changes could be detected. The fish from clean Kamennoe Lake (located in a protected area) had no pathological changes in the liver.     

Using the WTO/TBT enquiry point to monitor tendencies in the regulation of environment, health, and safety issues affecting the chemical industry

The growing importance of technical regulation affecting the use and sale of chemical products is a topic of interest not only for the chemical industry, but also for governments, nongovernmental organizations, consumers, and interested communities. The results of such regulation on behalf of the environment, health and safety of individuals, as well as its economic effects on industrial activity, are well understood in the United States and recently in the European Union. In less developed countries, however, the general level of public understanding of these issues is still minimal. It is common knowledge that the so-called "regulatory asymmetry" between countries at different levels of development contributes to the establishment of technical barriers to trade. Such asymmetries, however, also have other impacts: the displacement of polluting industrial sectors to countries which have less demanding regulations, the concentration of unsafe and harmful environmental conditions in certain parts of the globe, and the competitive disadvantage for industries located in countries where control is more rigid. This study analyses information on a wide range of technical regulations issued by World Trade Organization (WTO) members, and focuses on those regulations that affect the chemical industry. This information is available through the WTO Enquiry Points, organizations created in each country to administrate the Technical Barriers to Trade Agreement (TBT). This article consists of an analysis of 4,301 notifications of technical regulations by WTO member states in the 7-year period following the establishment of the WTO in 1995. Starting from this mass of information, 585 notifications that affect the circulation or use of chemical products were isolated. Of this group, 71% refer to only 15 countries. This group of notifications was further classified according to their motivation (the environment, health, safety), by the type of product affected (medications, fuels, hazardous products, etc.), by the type of country where it was established (developed, emerging or developing) and the existing conformity assessment mechanism (prohibition, licenses, certification, labeling, etc.). Beyond identifying tendencies in specific industrial sectors, the notifications studied here reach more than 100 chemical products, substances, preparations and other materials, which are subject to various levels of restrictions in different parts of the globe because of their composition or adverse reactions during their life cycles.     

Environmental health impacts of feeding crops to farmed fish

Half of the seafood consumed globally now comes from aquaculture, or farmed seafood. Aquaculture therefore plays an increasingly important role in the global food system, the environment, and human health. Traditionally, aquaculture feed has contained high levels of wild fish, which is unsustainable for ocean ecosystems as demand grows. The aquaculture industry is shifting to crop-based feed ingredients, such as soy, to replace wild fish as a feed source and allow for continued industry growth. This shift fundamentally links seafood production to terrestrial agriculture, and multidisciplinary research is needed to understand the ecological and environmental health implications. We provide basic estimates of the agricultural resource use associated with producing the top five crops used in commercial aquaculture feed. Aquaculture's environmental footprint may now include nutrient and pesticide runoff from industrial crop production, and depending on where and how feed crops are produced, could be indirectly linked to associated negative health outcomes. We summarize key environmental health research on health effects associated with exposure to air, water, and soil contaminated by industrial crop production. Our review also finds that changes in the nutritional content of farmed seafood products due to altered feed composition could impact human nutrition. Based on our literature reviews and estimates of resource use, we present a conceptual framework describing the potential links between increasing use of crop-based ingredients in aquaculture and human health. Additional data and geographic sourcing information for crop-based ingredients are needed to fully assess the environmental health implications of this trend. This is especially critical in the context of a food system that is using both aquatic and terrestrial resources at unsustainable rates.     

Regional dependence of urinary uranium baseline levels in non-exposed subjects with particular reference to volunteers from Northern Italy

Knowledge of the level of natural uranium (U) in the human body is fundamental in order to estimate the potentially hazardous incorporation in accidentally exposed subjects. A constant monitoring of exposed workers needs reliable reference baseline values, which can be determined by measuring the U concentration in urine. ICPMS has proven to be a fast, reliable and highly sensitive technique for this purpose. Non-uniformity in the distribution of U levels in various regions and differences in dietary habits account for the significant regional variations of U concentration in urine in non-exposed subjects. In this paper, the determination of daily uranium urinary excretion levels in a group of 12 non-exposed subjects from Northern Italy is presented and compared to data present in the published literature and to values obtained in a larger group of German volunteers. The urinary U output values observed in the Italian subset are generally higher than the corresponding levels measured in other groups. This could be the result of a higher intake of U from liquids, as assessed by the determination of U concentration in drinking waters.     

Recent levels of radionuclides in lichens from southwest Poland with particular reference to 134Cs and 137Cs

Analyses of Umbilicaria species collected from southwest Poland in August 1986 have shown there to be significant increases in levels of various radionuclides since previous analyses based on fieldwork in 1978–1979. The composition and ratio of the various radionuclides, particularly in respect of ¹³⁴Cs and ¹³⁷Cs, exhibit a characteristics signature consistent with contamination derived from the accident at the Chernobyl nuclear reactor in April 1986. Intraspecific variation in levels of ¹³⁷Cs in Umbilicaria is related to such factors as location, altitude and, to a lesser degree, aspect; interspecific variation in levels is related to ecological requirements and geographical pattern, and hence the same factors, although morphological differences in thalli may be implicated.     

Using fuzzy set theory to address the uncertainty of susceptibility to drought

This paper presents the technical aspects of a new methodology for assessing the susceptibility of society to drought. The methodology consists of a combination of inference modelling and fuzzy logic applications. Four steps are followed: (1) model input variables are selected—these variables reflect the main factors influencing susceptibility in a social group, population or region, (2) fuzzification—the uncertainties of the input variables are made explicit by representing them as ‘fuzzy membership functions’, (3) inference modelling—the input variables are used to construct a model made up of linguistic rules, and (4) defuzzification—results from the model in linguistic form are translated into numerical form, also through the use of fuzzy membership functions. The disadvantages and advantages of this methodology became apparent when it was applied to the assessment of susceptibility from three disciplinary perspectives: Disadvantages include the difficulty in validating results and the subjectivity involved with specifying fuzzy membership functions and the rules of the inference model. Advantages of the methodology are its transparency, because all model assumptions have to be made explicit in the form of inference rules; its flexibility, in that informal and expert knowledge can be incorporated through ‘fuzzy membership functions’ and through the rules in the inference model; and its versatility, since numerical data can be converted to linguistic statements and vice versa through the procedures of ‘fuzzification’ and ‘defuzzification’.     

Pollution characteristics and health risk assessment of volatile organic compounds emitted from different plastic solid waste recycling workshops

The pollution profiles of volatile organic compounds (VOCs) emitted from different recycling workshops processing different types of plastic solid waste (PSW) and their health risks were investigated. A total of 64 VOCs including alkanes, alkenes, monoaromatics, oxygenated VOCs (OVOCs), chlorinated VOCs (ClVOCs) and acrylonitrile during the melting extrusion procedure were identified and quantified. The highest concentration of total VOCs (TVOC) occurred in the poly(acrylonitrile-butadiene styrene) (ABS) recycling workshop, followed by the polystyrene (PS), polypropylene (PP), polyamide (PA), polyvinyl chloride (PVC), polyethylene (PE) and polycarbonate (PC) workshops. Monoaromatics were found as the major component emitted from the ABS and PS recycling workshops, while alkanes were mainly emitted from the PE and PP recycling processes, and OVOCs from the PVC and PA recycling workshops. According to the occupational exposure limits' (OEL) assessment, the workers suffered acute and chronic health risks in the ABS and PS recycling workshops. Meanwhile, it was found that most VOCs in the indoor microenvironments were originated from the melting extrusion process, while the highest TVOC concentration was observed in the PS rather than in the ABS recycling workshop. Non-cancer hazard indices (HIs) of all individual VOCs were < 1.0, whereas the total HI in the PS recycling workshop was 1.9, posing an adverse chronic health threat. Lifetime cancer risk assessment suggested that the residents also suffered from definite cancer risk in the PS, PA, ABS and PVC recycling workshops.