Reported Impact of COVID-19 Workload and Stressors on School Nurses' Provision of Care During the 2021-2022 School Year: A Secondary Analysis of U.S. School Nurse Survey Data.

Many school nurses experienced increased work burden and stress during the COVID-19 pandemic. This analysis examined data from a Centers for Disease Control and Prevention cross-sectional, nationwide survey of school nurses in March 2022 to examine associations between school nurses' ability to conduct their core responsibilities and selected nurse and school factors among school nurses during the 2021-2022 school year and COVID-19 pandemic. Perceived adequate staffing and financial compensation reduced the odds of reported difficulties across all core school nursing tasks. Nurses without a registered nurse license and with higher caseloads were more likely to report difficulty in implementing specific tasks. The impact of these factors varied, with inadequate financial compensation having the largest association with school nurses' difficulty implementing all the core responsibilities. The study results improve our understanding of school nurses' challenges in implementing core school nursing responsibilities during the COVID-19 pandemic in the 2021-2022 school year.

Tenant-Based Housing Voucher Programs: A Community Guide Systematic Review.

CONTEXT: Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing. OBJECTIVE: To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income. DESIGN: Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched. ELIGIBILITY CRITERIA: Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior. RESULTS: Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry. CONCLUSION: Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

Childhood Lead Poisoning: A Perpetual Environmental Justice Issue?

As the amount of lead in the environment has significantly decreased with the removal of lead in gasoline and paint, the United States has made great strides in preventing lead poisoning or reducing levels of lead in young children's blood. Even so, lead exposure is not equal for all children-low-income and minority children continue to bear a disproportionate burden of exposure primarily through contact with deteriorating lead-based paint from older housing and potentially through drinking contaminated water resulting from failing leaded pipes, as evidenced by the recent events in Flint, Michigan. These facts suggest that childhood lead poisoning is an environmental justice issue worthy of public health consideration and action; "environmental justice" is focused on identifying and addressing disproportionately high and adverse effects of environmental hazards on low-income and minority communities. The question remains, however, as to whether addressing the quality-of-life "risk" factors associated with lead poisoning might eventually lead to reduction in exposure, as well as potentially resulting in adverse health effects. Utilizing an environmental justice framework and examining this issue through a multidimensional environmental justice lens, we contemplated the quality-of-life factors that may essentially predispose minority children and their families to lead poisoning. Specifically, we examined American Community Survey data (2012-2016) focused on comparing race/ethnicity with other sociodemographic variables known to be associated with risks for childhood lead poisoning. The results provide thought-provoking context for making progress toward eliminating lead poisoning as a major environmental justice concern.

Blood Lead Levels Among Children Aged <6 Years - Flint, Michigan, 2013-2016.

During April 25, 2014-October 15, 2015, approximately 99,000 residents of Flint, Michigan, were affected by changes in drinking water quality after their water source was switched from the Detroit Water Authority (DWA), sourced from Lake Huron, to the Flint Water System (FWS), sourced from the Flint River.* Because corrosion control was not used at the FWS water treatment plant, the levels of lead in Flint tap water increased over time. Adverse health effects are associated with lead exposure (1). On January 2, 2015, a water advisory was issued because of detection of high levels of trihalomethanes, byproducts of disinfectants.(†)(,)(§) Studies conducted by local and national investigators detected an increase in the prevalence of blood lead levels (BLLs) ≥5 µg/dL (the CDC reference level) among children aged <5 years living in Flint (2) and an increase in water lead levels after the water source switch (3). On October 16, 2015, the Flint water source was switched back to DWA, and residents were instructed to use filtered tap water for cooking and drinking. During that time, pregnant and breastfeeding women and children aged <6 years were advised to consume bottled water.(¶) To assess the impact on BLLs of consuming contaminated drinking water, CDC examined the distribution of BLLs ≥5 µg/dL among children aged <6 years before, during, and after the switch in water source. This analysis enabled determination of whether the odds of having BLLs ≥5 µg/dL before the switch differed from the odds during the switch to FWS (before and after the January 2, 2015, water advisory was issued), and after the switch back to DWA. Overall, among 9,422 blood lead tests in children aged <6 years, 284 (3.0%) BLLs were ≥5 µg/dL during April 25, 2013-March 16, 2016. The adjusted probability of having BLLs ≥5 µg/dL was 46% higher during the period after the switch from DWA to FWS (and before the January 2, 2015, water advisory) than during the period before the water switch to FWS. Although unrelated to lead in the water, the water advisory likely reduced tap water consumption and increased consumption of bottled water. Characterizing exposure to lead contaminated drinking water among children aged <6 years living in Flint can help guide appropriate interventions.

Strengthening the capacity of local health agencies through community-based assessment and planning.

OBJECTIVES: We evaluated the effectiveness of the Protocol for Assessing Community Excellence in Environmental Health (PACE EH) in building competency in essential environmental health services and renewing efforts to engage the community in problem solving. Competency and community engagement have been identified by environmental health practitioners as important to meet new threats to public health. METHODS: We conducted a national survey and 24 case studies of public health agencies. We invited 917 organizations to participate in the national survey because they had requested a copy of the protocol. RESULTS: We received 656 total responses: 354 had not considered implementation, 302 had considered implementation, and 66 had implemented PACE EH. For the 24 case studies, we interviewed 206 individuals in communities implementing PACE EH. We found that PACE EH has had a positive effect on building community and professional networks, enhancing leadership, developing workforce competence, and expanding definitions of environmental health practice. CONCLUSIONS: With appropriate investments, PACE EH can be an effective tool to meet the environmental health challenges identified by local environmental health practitioners and state, tribal, and federal agencies.

A waterborne outbreak of gastroenteritis with multiple etiologies among resort island visitors and residents: Ohio, 2004.

BACKGROUND: The implementation of treated municipal water systems in the 20th century led to a dramatic decrease in waterborne disease in the United States. However, communities with deficient water systems still experience waterborne outbreaks. In August 2004, we investigated an outbreak of gastroenteritis on South Bass Island, Ohio, an island of 900 residents that is visited by >500,000 persons each year. METHODS: To identify the source of illness, we conducted a case-control study and an environmental investigation. A case was defined as diarrhea in a person who traveled to the island during the period from May 1 through 30 September 2004 and became ill within 2 weeks after the visit. Healthy travel companions served as matched control subjects. We also performed an environmental assessment and extensive testing of island water sources. RESULTS: Among the 1450 persons reporting illness, Campylobacter jejuni, norovirus, Giardia intestinalis, and Salmonella enterica serotype Typhimurium were identified in 16, 9, 3, and 1 persons, respectively. We interviewed 100 case patients and 117 matched control subjects. Case patients were more likely to drink water on the island than control subjects (68% vs. 35%; matched odds ratio, 4.3; 95% confidence interval, 2.2-9.3). Sampling of ground water wells indicated contamination with multiple fecal microbes, including Escherichia coli, C. jejuni, Salmonella species, and Giardia species. Irregularities in sewage disposal practices that could have contaminated the underground aquifer were noted. CONCLUSIONS: The combined epidemiological and environmental investigation indicated that sewage-contaminated ground water was the likely source of this large outbreak. Long-term changes to the island's water supply and sewage management infrastructure are needed.

Food service workers' self-reported food preparation practices: an EHS-Net study.

This study was conducted by the Environmental Health Specialists Network (EHS-Net), a network of environmental health specialists and epidemiologists at federal and state health agencies, whose mission is to improve environmental health practice. One of EHS-Net's primary goals is to improve the understanding of the underlying causes of foodborne illness using a system-based approach. As part of this ongoing effort, EHS-Net analyzed data from a telephone survey of food service workers designed to increase our understanding of food preparation practices (a cause of foodborne illness) in restaurants. Results indicated that risky food preparation practices were commonly reported. Respondents said that at work they did not always wear gloves while touching ready-to-eat (RTE) food (60%), did not always wash their hands or change their gloves between handling raw meat and RTE food (23% and 33%), did not use a thermometer to check food temperatures (53%), and had worked while sick with vomiting or diarrhea (5%). Several factors were associated with safer food preparation practices. Workers responsible for food preparation reported washing their hands and wearing gloves when handling RTE food more often than workers not responsible for food preparation. Workers who cooked reported changing their gloves more often than workers who did not cook. Older workers and managers reported washing their hands more often than younger workers and non-managers. Workers in chain restaurants more frequently reported using thermometers than workers in independently owned restaurants. This study provides valuable information concerning the prevalence of food preparation practices and factors that may impact those practices. Additional research is needed to better understand those factors.

Use of a systems-based approach to an environmental health assessment for a waterborne disease outbreak investigation at a snowmobile lodge in Wyoming.

Investigations into disease outbreaks generally incorporate an epidemiologic investigation, laboratory analysis, and an environmental health assessment. This last component is designed to discover connections between factors in the environment and the outbreak, but is often limited, either by time and resources, or the expertise of the personnel included in outbreak investigation teams. A waterborne Norovirus outbreak investigation in Sheridan County, Wyoming, in 2001 provides an excellent example of the importance of including an in-depth, systems-based environmental health assessment in outbreak investigations. The epidemiologic component of this investigation identified the water supply of a snowmobile lodge in the Bighorn Mountains as the source of the outbreak, a result that was confirmed by laboratory analysis. Including a systems-based environmental health assessment in this investigation also helped to uncover the underlying environmental factors that led to contamination of the water supply. Those factors included an onsite wastewater disposal system that was overloaded by increased use and not well suited to local soil and geologic conditions and a drinking water system with no treatment or disinfection. In addition, heavy precipitation and increased pumping of wells to satisfy higher demands probably facilitated the contamination of the drinking water wells by causing greater movement of wastewater through the soil and underlying bedrock. By focusing on these links between factors in the environment and adverse health outcomes, the systems-based environmental health assessment also helped to highlight prevention strategies for avoiding recurrences.

A federal agency's role in fulfilling the public health core functions: the childhood lead poisoning prevention program model.

The Institute of Medicine identified 3 core functions of public health: assessment, policy development, and assurance. Federal, state, and local public health agencies all have an obligation to provide these vital functions to ensure conditions in which people can be healthy. However, the few publications that provide core function applications only focus on applications at the local or state levels. The Centers for Disease Control and Prevention's Childhood Lead Poisoning Prevention Program uses a comprehensive public health approach. This article describes the Centers for Disease Control and Prevention's leading role in applying the core public health functions to prevent childhood lead poisoning.

Blood lead levels and risk factors for lead poisoning among children in a Mexican smelting community.

The authors evaluated mean blood lead levels (BLLs) and the prevalence of elevated BLLs in children 1-6 yr of age living in Torreón, Mexico, and assessed risk factors for lead exposure in these children. The study involved a simple random sample of households in the area around a local smelter, as well as a 2-stage cluster sample of neighborhoods and households in the remainder of Torreón. The geometric mean BLL of children in this study (N = 367) was 6.0 microg/dl (95% confidence interval [CI] = 5.2, 6.8) (0.29 microM/l [95% CI = 0.25, 0.33]). Twenty percent of the children had BLLs > or = 10 microg/dl (0.48 microM/l), and 5% had BLLs > or = 20 microg/dl (0.97 microM/l). In multivariate analyses, distance from the smelter, amount of income, and education level of the primary caregiver predicted BLLs. In the environmental risk factor subsample (n = 124), dust and soil lead levels were associated with BLLs and distance from the smelter. BLLs in this study were moderately high, but the levels were lower than those in other smelting communities prior to remediation.

Blood lead levels and risk factors for lead poisoning among children in Jakarta, Indonesia.

The phase-out of leaded gasoline began in Jakarta, Indonesia on July 1, 2001. We evaluated mean blood lead levels (BLLs) and the prevalence of elevated BLLs of Jakarta school children and assessed risk factors for lead exposure in these children before the beginning of the phase-out activities. The study involved a population-based, cross-sectional blood lead survey that included capillary blood lead sampling and a brief questionnaire on risk factors for lead poisoning. A cluster survey design was used. Forty clusters, defined as primary schools in Jakarta, and 15 2nd- and 3rd-grade children in each cluster were randomly selected for participation in the study. The average age of children in this study was 8.6 years (range 6-12) and the geometric mean BLL of the children was 8.6 microg/dl (median: 8.6 microg/dl; range: 2.6-24.1 microg/dl) (n=397). Thirty-five percent of children had BLLs > or =10 microg/dl and 2.4% had BLLs > or =20 microg/dl. Approximately one-fourth of children had BLLs 10-14.9 microg/dl. In multivariate models, level of education of the child's primary caregiver, water collection method, home varnishing and occupational recycling of metals, other than lead, by a family member were predictors of log BLLs after adjustment for age and sex. BLLs of children who lived near a highway or major intersection were significantly higher than those of children who lived near a street with little or no traffic when level of education was not included in the model. Water collection method was a significant predictor of BLLs > or =10 microg/dl after adjustment for age and sex. BLLs in children in this study were moderately high and consistent with BLLs of children in other countries where leaded gasoline is used. With the phase-out of leaded gasoline, BLLs of children in Jakarta are expected to rapidly decline as they have in other countries that have phased lead out of gasoline.

New approaches to safe drinking water.

Up to half the population of some states in the United States drink water from small systems not regulated by the Safe Drinking Water Act. The quality of the drinking water from these systems is generally unknown and may be suspect. In many jurisdictions, private wells are the primary source of water. In some instances, construction of wells may have met regulatory requirements but may not have adequately prevented disease transmission. Anecdotal information, periodic water-borne outbreaks, and recent well surveys suggest that there are public health concerns associated with these and similar systems. This article provides an assessment of the need for governmental oversight (regulatory and non-regulatory) of drinking water supplies, describes how a "systems-based" approach might be used to evaluate water supply systems and to identify and prevent possible contamination, and presents case studies describing the systems-based approach as well as a comprehensive approach to environmental health that includes drinking water regulation.