A review of the public health impacts of unconventional natural gas development.

The public health impact of hydraulic fracturing remains a high profile and controversial issue. While there has been a recent surge of published papers, it remains an under-researched area despite being possibly the most substantive change in energy production since the advent of the fossil fuel economy. We review the evidence of effects in five public health domains with a particular focus on the UK: exposure, health, socio-economic, climate change and seismicity. While the latter would seem not to be of significance for the UK, we conclude that serious gaps in our understanding of the other potential impacts persist together with some concerning signals in the literature and legitimate uncertainties derived from first principles. There is a fundamental requirement for high-quality epidemiological research incorporating real exposure measures, improved understanding of methane leakage throughout the process, and a rigorous analysis of the UK social and economic impacts. In the absence of such intelligence, we consider it prudent to incentivise further research and delay any proposed developments in the UK. Recognising the political realities of the planning and permitting process, we make a series of recommendations to protect public health in the event of hydraulic fracturing being approved in the UK.

Environmental Public Health Tracking: a cost-effective system for characterizing the sources, distribution and public health impacts of environmental hazards.

Background: The contemporary environment is a complex of interactions between physical, biological, socio-economic systems with major impacts on public health. However, gaps in our understanding of the causes, extent and distribution of these effects remain. The public health community in Sandwell West Midlands has collaborated to successfully develop, pilot and establish the first Environmental Public Health Tracking (EPHT) programme in Europe to address this 'environmental health gap' through systematically linking data on environmental hazards, exposures and diseases. Methods: Existing networks of environmental, health and regulatory agencies developed a suite of innovative methods to routinely share, integrate and analyse data on hazards, exposures and health outcomes to inform interventions. Results: Effective data sharing and horizon scanning systems have been established, novel statistical methods piloted, plausible associations framed and tested, and targeted interventions informed by local concerns applied. These have influenced changes in public health practice. Conclusion: EPHT is a powerful tool for identifying and addressing the key environmental public health impacts at a local level. Sandwell's experience demonstrates that it can be established and operated at virtually no cost. The transfer of National Health Service epidemiological skills to local authorities in 2013 provides an opportunity to expand the programme to fully exploit its potential.

Behavior outdoors and its effects on personal ultraviolet exposure rate measured using an ambulatory datalogging dosimeter.

We describe the construction of a small device incorporating a UVB (290-320 nm) sensor that can be worn on the lapel site or waistband and which is electrically coupled to a portable data logger carried in a trouser pocket or worn on a belt. The detector has an approximate cosine-weighted angular response and is linear over a wide dynamic range. It has a spectral sensitivity that follows closely the erythema action spectrum in the UVB region, is less than one order of magnitude greater than this action spectrum in the UVAII region (320-340 nm) and between one to two orders of magnitude greater in the UVAI region (340-400 nm). The instrument has been used to monitor variations in erythemally effective exposure rate that occurred during three outdoor activities with differing weather conditions. Erythemal irradiance incident on the trunk was recorded every 2 s for periods ranging from 1 to 2.2 h. The results demonstrated that behavior outdoors can be a more dominant factor in determining personal exposure than ambient ultraviolet and highlighted the very important role that shade from trees plays in reducing exposure.

The design and evaluation of an automated system for monitoring 133Xe in room air.

The radioactive gas 133Xe is widely used for ventilation imaging. This paper describes a system for continuous monitoring of the air concentration of 133Xe. The instrument consisted of a sodium iodide scintillation detector, a scaler/ratemeter and a data logger. The crystal was mounted inside a lead shield and enclosed in a perspex cylinder. A fan at one end of the cylinder drew room air into a shielded active volume via an inlet aperture designed to generate turbulent flow with no stagnant areas. The instrument was rendered relatively insensitive to external radiation by positioning the energy window over the 31 keV peak in the 133Xe spectrum. The detector sensitivity was approximately 2 s-1 per MBq m-3, with a typical background count rate of 0.12 s-1. The system was therefore capable of detecting a concentration of 0.06 MBq m-3 in a one-minute sampling interval. Results collected at five centres demonstrated that the eight-hour time-averaged concentrations were much less than the derived air concentration (DAC) for occupationally exposed persons (mean values 0.4 to 1.5% of the DAC), but that transient concentrations were extremely variable (mean values 7 to 24% of the DAC).

Temporal and seasonal variation in the occurrence of chemical incidents.

AIMS: To determine whether there were temporal or seasonal patterns in the occurrence of chemical incidents reported to the West Midlands Chemical Incident Surveillance System, UK. METHODS: A retrospective analysis of reports maintained on a computerised database was carried out for information received from January 1997 to December 2001. RESULTS: Annual numbers of events increased significantly from 77 (7.5%) in 1997 to 282 (27.4%) in 2001. Compared to the average of other seasons, proportionately more incidents occurred in the summer (29.3%). Compared with the average of other days, incidents were more likely to occur on Thursdays (17.1%) and least likely on Saturdays (8.9%). When grouped together on a six hourly basis incidents were most frequent between 12 00 and 17 59 (31.1%) and least frequent between 00 00 and 05 59 (21.2%). CONCLUSIONS: The surveillance system shows that chemical incidents do not occur randomly but have marked temporal and seasonal variation. These results have implications for service provision, training, and the development of preventive strategies.

Congenital and developmental anomalies of the genitalia of slaughtered bulls.

The genital tracts of 968 slaughtered bulls (46% of which were young post-puberal animals) were examined for defects of a congenital or developmental nature. The overall occurrence of such lesions was 7%. These comprised persistent penile frenulum (0.5%), hypospadias (0.3%), detached urethral process (0.4%), testicular hypoplasia (0.2%), cryptorchidism (0.6%), mesonephric duct abnormalities (1.1%) and bulbourethral cysts, fusion and aplasia (3.6%). Segmental aplasia of the mesonephric duct, not previously recorded in the study area, was found in 4 Shorthorn bulls (0.4%); 2 affected animals were from one herd. In 3 cases of hypospadias (2 from one herd), the urethra communicated with the ventral surface of the penis at the junction of the body and glans through a slit-like orifice. The occurrence of defects observed was generally comparable to that found in bull populations elsewhere but elevated occurrence of several defects in particular herds emphasized the need for further study.

Hyperbaric oxygen therapy in the management of carbon monoxide poisoning, osteoradionecrosis, burns, skin grafts, and crush injury.

OBJECTIVES: To systematically assess the evidence for effectiveness of hyperbaric oxygen therapy in the treatment of conditions of significance in the West Midlands region and to determine whether there is a case for establishing a hyperbaric oxygen unit in the region. METHODS: Systematic review of the literature assessing randomized controlled trials from 1968 onward. RESULTS: A total of 154 full-text articles was obtained of which 13 relevant randomized control trials were identified. There was little consistency in the studies. Treatment protocols, study groups, time to treatment, and other characteristics and outcomes measured all varied considerably. No convincing evidence of effectiveness was identified. CONCLUSIONS: Although hyperbaric oxygen therapy is clearly appropriate in the treatment of decompression sickness and air/gas embolism, there is no convincing evidence of effectiveness for the conditions reviewed, despite its widespread use. Although this review has found no evidence to support the establishment of a unit in the West Midlands, there is a physiological case for an effect in conditions involving hypoxia and, given the limited volume (and in some cases quality) of published research, a case for a national research program.

Ambulatory monitoring of ultraviolet erythema in photosensitive subjects.

Little is known about whether patients with photosensitive disorders exhibit a different ultraviolet erythema time course from subjects with a normal response to sunlight. We have described the application of an instrument for ambulatory monitoring of the development of ultraviolet erythema by a reflectance method in a group of patients with chronic actinic dermatitis (CAD) and in a group of normal subjects. Investigations of the time course have been reported previously but the techniques used relied upon manual measurement. Consequently sampling frequencies have been considerably lower than the one-minute sample rate used here. We have not demonstrated any difference in the rate at which erythema develops and peaks between patients with CAD and subjects with a normal response to sunlight.

An epidemiological study of acute carbon monoxide poisoning in the West Midlands.

OBJECTIVES: To describe the epidemiology of carbon monoxide (CO) poisoning in a defined population, identifying those at greatest risk from acute poisoning resulting in admission to hospital or death. METHODS: A retrospective study with routinely collected information, set in the former West Midlands Regional Health Authority; population of 5.2 million. The data comprised 939 deaths and 701 hospital admissions due to CO poisoning between January 1988 to December 1994. The main outcome measures were age and sex standardised incidence rates (SIRs) for non-intentional, suicidal, and undetermined poisonings for health authorities and the linear relation with socioeconomic deprivation. RESULTS: Overall rate of non-intentional poisonings over the 7 year period was 7.6/100,000, an annual rate of 1.1/100,000. The 7 year rates were highest in people > or = 85; men 24.0/100,000 and women 19.7/100,000. For suicides the 7 year rate was 19.6/100,000, an annual rate of 2.8/100,000. The 7 year rates were highest for men of 35-39, 64.1/100,000, and for women aged 45-49, 15.3/100,000. None of the causes of poisoning were related to deprivation. Non-intentional poisonings showed a strong seasonal variation with the highest rates being recorded in the months October to March. Increased rates of poisoning were found in the rural districts of the West Midlands. There seems to have been a decline in suicides coinciding with the introduction of three way catalytic converters on cars. CONCLUSIONS: Elderly people and the very young are at the greatest risk from non-intentional CO poisoning and rates are highest in the winter months. Although deaths from non-intentional CO poisoning are declining nationally, in the West Midlands they have remained stable and hospital admissions are increasing. It is not solely an urban phenomenon with rates for non-intentional CO poisoning and suicides higher in the rural districts. Health authorities need to consider all populations in any prevention programme. Further work is needed to establish the extent of the burden of chronic CO poisoning and the impact of catalytic converters on suicides.

Comparison of the psychiatry learning system and traditional teaching of psychiatry.

Pressures of time, changing curricula, and increased enrollment in medical schools require the development of more efficient teaching methods to replace or supplement the traditional lecture format. The faculty of the Department of Psychiatry and Behavioral Sciences at the Medical University of South Carolina has developed an individualized course in basic psychiatry which can replace approximately 50 hours of lectures ordinarily delivered to students during the rotation on clinical psychiatry. The individualized course, referred to as the Psychiatry Learning System (PLS), was received by half the class during the year 1973-74, and the lecture course was delivered to the other half. These two groups were compared on several learning outcomes, including attainment of theoretical knowledge about psychiatry, observational skills, interviewing ability, and problem-solving ability. Overall performance ratings by clinical supervisors were also obtained. The PLS group scored no worse on any of the measures but statistically better on half of them than did the lecture group.

A device for phototesting patients before PUVA therapy.

A device is described and validated for rapid and easy phototesting of patients at the start of a course of PUVA therapy. The phototesting template consists of metal foil with four apertures of 10 mm diameter, mounted in pliable polyurethane. One aperture is open, and the other three each incorporate a grid of hexagonal holes of differing size which attenuate the radiation, resulting in relative intensities at the skin surface of 1, 2, 4 and 8. Thus, a single exposure through the foil of, for example, 8 J/cm2, would allow the minimal phototoxic dose to be determined as either 1, 2, 4, 8, or > 8 J/cm2. The device was validated by comparison with a metal foil with four open apertures, but otherwise identical construction, in which the dose was controlled by varying the exposure time. In 11 subjects, tested with one device on each arm, the minimal phototoxic dose, judged visually, was identical. Reflectance measurements of erythema at each of the test sites showed no systematic difference between the two methods. The device has no moving parts, requires no source of electrical power, will not change its optical transmission with age, and is robust and easy to use. It should, therefore, allow much wider application of the useful technique of minimal phototoxic dose determination before PUVA therapy.

Phototesting prior to narrowband (TL-01) ultraviolet B phototherapy.

A device for phototesting patients prior to narrowband phototherapy is described. One hundred and fifty patients (130 with psoriasis and 20 with eczema) of skin types I-IV were phototested on the forearm and 22 on both forearm and back. The minimal erythema dose (MED) was judged visually 24 h after irradiation, and in those patients who were tested at two body sites, objective measurement of the erythema was made using a reflectance instrument. The MED values on the arm showed a fivefold range. There was no significant association between skin type and MED. The MED values on the arm were significantly higher than those measured on the back, although the differences were small in the majority of cases. No significant difference was found between the slopes of the dose-response curves measured on the arm and on the back.

A large outbreak of Q fever in the West Midlands: windborne spread into a metropolitan area?

The largest outbreak of the zoonotic disease Q fever recorded in the United Kingdom (UK) occurred in Birmingham in 1989. One hundred and forty-seven cases were identified, 125 of whom were males, and 130 of whom were between 16 and 64 years of age. Fewer cases of Asian ethnic origin were observed than expected (p < 0.01), and more smokers (p < 0.005). A case control study (26 cases and 52 matched controls) produced no evidence that direct contact with animals or animal products had caused the outbreak. The epidemic curve suggested a point source exposure in the week beginning 10 April. The home addresses of cases were clustered in a rectangle 11 miles (18.3 km) north/south by 4 miles (6.7 km) east/ west, and attack rates became lower towards the north. Directly south of this area were farms engaged in outdoor lambing and calving, a potent source of coxiella spores. A retrospective computerised analysis showed that the geographical distribution of cases was associated with a source in this area (p < 0.00001). On 11 April, unusual southerly gales of up to 78 mph (130 km/h) were recorded. The probable cause of the outbreak was windborne spread of coxiella spores from farmland to the conurbation.