The design and evaluation of a system for improved surveillance and prevention programmes in resource-limited settings using a hospital-based burn injury questionnaire.

BACKGROUND: Limited and fragmented data collection systems exist for burn injury. A global registry may lead to better injury estimates and identify risk factors. A collaborative effort involving the WHO, the Global Alliance for Clean Cookstoves, the CDC and the International Society for Burn Injuries was undertaken to simplify and standardise inpatient burn data collection. An expert panel of epidemiologists and burn care practitioners advised on the development of a new Global Burn Registry (GBR) form and online data entry system that can be expected to be used in resource-abundant or resource-limited settings. METHODS: International burn organisations, the CDC and the WHO solicited burn centre participation to pilot test the GBR system. The WHO and the CDC led a webinar tutorial for system implementation. RESULTS: During an 8-month period, 52 hospitals in 30 countries enrolled in the pilot and were provided the GBR instrument, guidance and a data visualisation tool. Evaluations were received from 29 hospitals (56%). KEY FINDINGS: Median time to upload completed forms was <10 min; physicians most commonly entered data (64%), followed by nurses (25%); layout, clarity, accuracy and relevance were all rated high; and a vast majority (85%) considered the GBR 'highly valuable' for prioritising, developing and monitoring burn prevention programmes. CONCLUSIONS: The GBR was shown to be simple, flexible and acceptable to users. Enhanced regional and global understanding of burn epidemiology may help prioritise the selection, development and testing of primary prevention interventions for burns in resource-limited settings.

Mortality among military participants at the 1957 PLUMBBOB nuclear weapons test series and from leukemia among participants at the SMOKY test.

Health effects following low doses of ionizing radiation are uncertain. Military veterans at the Nevada test site (NTS) during the SMOKY atmospheric nuclear weapons test in 1957 were reported to be at increased risk for leukemia in 1979, but this increase was not evaluated with respect to radiation dose. The SMOKY test was one of 30 tests in 1957 within the PLUMBBOB test series. These early studies led to public laws where atomic veterans could qualify for compensation for presumptive radiogenic diseases. A retrospective cohort study was conducted of 12219 veterans at the PLUMBBOB test series, including 3020 at the SMOKY nuclear test. Mortality follow-up was through 2010 and observed causes of death were compared with expected causes based on general population rates. Radiation dose to red bone marrow was based on individual dose reconstructions, and Cox proportional hazards models were used to evaluate dose response for all leukemias other than chronic lymphocytic leukemia (non-CLL leukemia). Vital status was determined for 95.3% of the 12 219 veterans. The dose to red bone marrow was low (mean 3.2 mGy, maximum 500 mGy). Military participants at the PLUMBBOB nuclear test series remained relatively healthy after 53 years and died at a lower rate than the general population. In contrast, and in comparison with national rates, the SMOKY participants showed significant increases in all causes of death, respiratory cancer, leukemia, nephritis and nephrosis, and accidents, possibly related in part to lifestyle factors common to enlisted men who made up 81% of the SMOKY cohort. Compared with national rates, a statistically significant excess of non-CLL leukemia was observed among SMOKY participants (Standardized Mortality Ratio = 1.89, 95% 1.24-2.75, n = 27) but not among PLUMBBOB participants after excluding SMOKY (SMR = 0.87, 95% 0.64-1.51, n = 47). Leukemia risk, initially reported to be significantly increased among SMOKY participants, remained elevated, but this risk diminished over time. Despite an intense dose reconstruction, the risk for leukemia was not found to increase with increasing levels of radiation dose to the red bone marrow. Based on a linear model, the estimated excess relative risk per mGy is -0.05 (95% CI -0.14, 0.04). An explanation for the observed excess of leukemia remains unresolved but conceivably could be related to chance due to small numbers, subtle biases in the study design and/or high tobacco use among enlisted men. Larger studies should elucidate further the possible relationship between fallout radiation, leukemia and cancer among atomic veterans.

Epidemiology and Outcomes of Cooking- and Cookstove-Related Burn Injuries: A World Health Organization Global Burn Registry Report.

Cooking- and cookstove-related burns (CSBs) comprise a large proportion of burn injuries globally, but there are limited data on cooking behavior patterns to inform prevention and advocacy. Therefore, we aimed to describe the epidemiology, risk factors, and outcomes of these injuries and highlight the potential of the World Health Organization (WHO) Global Burn Registry (GBR). Patients with cooking-related burns were identified in the WHO GBR. Patient demographics, cooking arrangement, injury characteristics, and outcomes were described and compared. Bivariate regression was performed to identify risk factors associated with CSBs. Analysis demonstrated that 25% of patients in the GBR sustained cooking-related burns (n = 1723). The cooking environment and cooking fuels used varied significantly by country income level ([electricity use: LIC 1.6 vs MIC 5.9 vs HIC 49.6%; P < .001] [kerosene use: LIC 5.7 vs MIC 10.4 vs HIC 0.0%; P < .001]). Of cooking-related burns, 22% were cookstove-related burns (CSBs; 311 burns). Patients with CSBs were more often female (65% vs 53%; P < .001). CSBs were significantly larger in TBSA size (30%, IQR 15-45 vs 15%, IQR 10-25; P < .001), had higher revised Baux scores (70, IQR 46-95 vs 28, IQR 10-25; P < .001) and more often resulted in death (41 vs 11%; P < .001) than other cooking burns. Patients with CSBs were more likely to be burned by fires (OR 4.74; 95% CI 2.99-7.54) and explosions (OR 2.91, 95% CI 2.03-4.18) than other cooking injuries. Kerosene had the highest odds of CSB compared to other cooking fuels (OR 2.37, 95% CI 1.52-3.69). In conclusion, CSBs specifically have different epidemiology than cooking-related burns. CSBs were more likely caused by structural factors (eg, explosion, fire) than behavioral factors (eg, accidental movements) when compared to other cooking burns. These differences suggest prevention interventions for CSBs may require distinctive efforts than typically deployed for cooking-related injuries, and necessarily involve cookstove design and safety regulations to prevent fires and explosions.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey.

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43-79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

Environmental- and injury-related epidemic-assistance investigations, 1946-2005.

This paper summarizes environmental investigations (n = 458) conducted during the first 60 years of the epidemic-assistance investigation program at the Centers for Disease Control and Prevention. These investigations were grouped into 10 categories: toxic chemicals (n = 102), indoor air quality and outdoor air toxics (n = 21), new or rare epidemic diseases and unexplained syndromes (n = 29), natural disasters (n = 81), terrorism and unintentional human-made disasters (n = 9), substance use and abuse (n = 13), environmental aspects of infectious disease (n = 132), those affecting neonates and infants (n = 11), violence and injuries (n = 51), and miscellaneous (n = 9). Among the most important or prominent were studies of lead and arsenic toxicity at smelters, mercury in paint and beauty creams, dioxin in waste oil in Missouri, polychlorinated biphenyls and multiple other toxic chemicals, global pesticide poisoning outbreaks, hepatic angiosarcoma among vinyl chloride workers, toxic oil syndrome in Spain, eosinophilia-myalgia syndrome from contaminated L-tryptophan, diethylene glycol poisoning in Haiti, aflatoxicosis in Kenya, Gulf War illness among veterans, impact and needs assessments during natural disasters (e.g., Hurricane Katrina (2005) and the Mount St. Helens volcano eruptions (1980)), risk factors for heat-related mortality, domestic and international terrorist attacks, Parkinsonism related to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine in California, and unintentional injury- and violence-related events.

Burn injury prevention in low- and middle- income countries: scoping systematic review.

BACKGROUND: Burn injuries are a leading cause of morbidity and disability, with the burden of disease being disproportionately higher in low- and middle-income countries (LMIC). Burn prevention programmes have led to significant reductions in the incidence of burns in high-income countries. However, a previous systematic review published in 2015 highlighted that implementation and evaluation of similar programmes has been limited in LMIC. The objective of this scoping review and narrative synthesis was to summarise and understand the initiatives that have been carried out to reduce burn injuries in LMIC and their effectiveness. METHODS: We aimed to identify publications that described studies of effectiveness of burn prevention interventions applied to any population within a LMIC and measured burn incidence or burns-related outcomes. Suitable publications were identified from three sources. Firstly, data was extracted from manuscripts identified in the systematic review published by Rybarczyk et al. We then performed a search for manuscripts on burn prevention interventions published between January 2015 and September 2020. Finally, we extracted data from two systematic reviews where burn evidence was not the primary outcome, which were identified by senior authors. A quality assessment and narrative synthesis of included manuscripts were performed. RESULTS: In total, 24 manuscripts were identified and categorized according to intervention type. The majority of manuscripts (n = 16) described education-based interventions. Four manuscripts focused on environmental modification interventions and four adopted a mixed-methods approach. All of the education-based initiatives demonstrated improvements in knowledge relating to burn safety or first aid, however few measured the impact of their intervention on burn incidence. Four manuscripts described population-based educational interventions and noted reductions in burn incidence. Only one of the four manuscripts describing environmental modification interventions reported burns as a primary outcome measure, noting a reduction in burn incidence. All mixed-method interventions demonstrated some positive improvements in either burn incidence or burns-related safety practices. CONCLUSION: There is a lack of published literature describing large-scale burn prevention programmes in LMIC that can demonstrate sustained reductions in burn incidence. Population-level, collaborative projects are necessary to drive forward burn prevention through specific environmental or legislative changes and supplementary educational programmes.

Global approach to reducing lead exposure and poisoning.

Lead poisoning is an important environmental disease that can have life-long adverse health effects. Most susceptible are children, and most commonly exposed are those who are poor and live in developing countries. Studies of children's blood-lead levels (BLLs) are showing cognitive impairment at increasingly lower BLLs. Lead is dangerous at all levels in children. The sources of lead exposure vary among and within countries depending on past and current uses. Sources of lead may be from historic contamination, recycling old lead products, or from manufacturing new products. In all countries that have banned leaded gasoline, average population BLLs have declined rapidly. In many developing countries where leaded gasoline is no longer used, many children and workers are exposed to fugitive emissions and mining wastes. Unexpected lead threats, such as improper disposal of electronics and children's toys contaminated with lead, continue to emerge. The only medical treatment available is chelation, which can save lives of persons with very high BLLs. However, chelating drugs are not always available in developing countries and have limited value in reducing the sequelae of chronic low dose lead exposure. Therefore, the best approach is to prevent exposure to lead. Because a key strategy for preventing lead poisoning is to identify and control or eliminate lead sources, this article highlights several major sources of lead poisoning worldwide. In addition, we recommend three primary prevention strategies for lead poisoning: identify sources, eliminate or control sources, and monitor environmental exposures and hazards.

Mold prevention strategies and possible health effects in the aftermath of hurricanes and major floods.

Extensive water damage after major hurricanes and floods increases the likelihood of mold contamination in buildings. This report provides information on how to limit exposure to mold and how to identify and prevent mold-related health effects. Where uncertainties in scientific knowledge exist, practical applications designed to be protective of a person's health are presented. Evidence is included about assessing exposure, clean-up and prevention, personal protective equipment, health effects, and public health strategies and recommendations. The recommendations assume that, in the aftermath of major hurricanes or floods, buildings wet for <48 hours will generally support visible and extensive mold growth and should be remediated, and excessive exposure to mold-contaminated materials can cause adverse health effects in susceptible persons regardless of the type of mold or the extent of contamination. For the majority of persons, undisturbed mold is not a substantial health hazard. Mold is a greater hazard for persons with conditions such as impaired host defenses or mold allergies. To prevent exposure that could result in adverse health effects from disturbed mold, persons should 1) avoid areas where mold contamination is obvious; 2) use environmental controls; 3) use personal protective equipment; and 4) keep hands, skin, and clothing clean and free from mold-contaminated dust. Clinical evaluation of suspected mold-related illness should follow conventional clinical guidelines. In addition, in the aftermath of extensive flooding, health-care providers should be watchful for unusual mold-related diseases. The development of a public health surveillance strategy among persons repopulating areas after extensive flooding is recommended to assess potential health effects and the effectiveness of prevention efforts. Such a surveillance program will help CDC and state and local public health officials refine the guidelines for exposure avoidance, personal protection, and clean-up and assist health departments to identify unrecognized hazards.

Examples of applied public health through the work of the Epidemic Intelligence Service officers at CDC's National Center for Environmental Health: 2006-2015.

The Epidemic Intelligence Service officers (EISOs) at the National Center for Environmental Health (NCEH)/Agency for Toxic Substances and Disease Registry (ATSDR) respond to public health outbreaks, assist public health surveillance, and recommend public health actions. We summarize the breadth of work done by EISOs assigned to NCEH/ATSDR during 2006-2015. We used the Web of Science, Scopus, and PubMed databases to identify articles authored by the EISOs, number and types of epidemiologic assistance field investigations (Epi-Aids), and interviewed NCEH/ATSDR programs with EISO assignees. The largest number of NCEH/ATSDR EISO publications (n = 61) and Epi-Aids (n = 110) related to toxic chemicals (23 and 37, respectively), followed by natural disasters and those caused by humans (19 and 25, respectively), extreme temperature-related illness (9), and chronic diseases (8). The investigations raised awareness, identified risk factors and public health needs, and introduced better prevention and protection measures for human health. Through field investigations and other technical assistance, NCEH/ATSDR provided leadership and staff scientists to assist in the field, as well as knowledge transfer to local, state, territorial, and international health departments.

Health effects of hazardous waste.

Since 1995, the Agency for Toxic Substances and Disease Registry (ATSDR) has evaluated environmental contaminants and human health risks at nearly 3000 sites. Hazardous substances at these sites include newly emerging problems as well as historically identified threats. ATSDR classifies sites according to the degree of hazard they represent to the public. Less than 1% of the sites investigated are considered urgent public health hazards where chemical or physical hazards are at levels that could cause an immediate threat to life or health. Approximately 20% of sites have a potential for long-term human exposures above acceptable risk levels. At almost 40% of sites, hazardous substances do not represent a public health hazard. Completed exposure pathways for contaminants in air, water, and soil have been reported at approximately 30% of evaluated sites. The most common contaminants of concern at these sites include heavy metals, volatile organic compounds, and polychlorinated biphenyls. This article reviews ATSDR's ongoing work by examining the historic hazard of lead, the contemporary hazard of asbestos, and the emerging issue of perchlorate contamination.

Perspectives on the use of scientific knowledge for public health practice.

Achieving the goal of increasing quality and years of healthy life is fundamentally based on success in the practice of public health. As our life style changes with time and as public health issues become more global, the practice of public health is enhanced to meet new challenges. In addition to addressing infectious diseases, environmental concerns are gaining attention. New challenges require the modification of the methods of investigations, use of new technologies and application of real-time management of public health emergencies. In many situations, collaborations at the local, regional, national and global levels are needed. This manuscript provides a summary of the approaches to address certain crucial environmental health concerns towards the goal of increasing quality and years of healthy life.

Addressing community concerns about asthma and air toxics.

People with asthma who live near or downwind from a source of toxic emissions commonly express concerns about the possible impact of hazardous air pollution on their health, especially when these emissions are visible or odorous. Citizens frequently turn to their local and state health departments for answers, but health departments face many challenges in addressing these concerns. These challenges include a lack of asthma statistics at the local level, limited exposure information, and a paucity of scientific knowledge about the contributions of hazardous air pollutants to asthma induction or exacerbation. Health agencies are creatively developing methods to address these challenges while working toward improving asthma surveillance data at the state and local levels. Recent community health investigations suggest that hazardous air pollutants that are occupational asthmagens or associated with odors may deserve more attention. In seeking to address community concerns about hazardous air pollution and asthma, community health investigations may also help to fill gaps in our scientific knowledge and identify areas for further research or environmental intervention. The solutions to community problems associated with environmental contamination and asthma, however, require sustained, coordinated efforts by public and private groups and citizens. Public health agencies can make a unique contribution to this effort, but additional resources and support will be required to develop information systems and epidemiologic capacity at the state and local levels.

An international perspective on hazardous waste practices.

In developing countries, public health attention is focused on urgent health problems such as infectious diseases, malnutrition, and infant mortality. As a country develops and gains economic resources, more attention is directed to health concerns related to hazardous chemical wastes. Even if a country has little industry of its own that generates hazardous wastes, the importation of hazardous wastes for recycling or disposal can present health hazards. It is difficult to compare the quantities of hazardous wastes produced in different countries because of differences in how hazardous wastes are defined. In most countries, landfilling is the most common means of hazardous waste disposal, although substantial quantities of hazardous wastes are incinerated in some countries. Hazardous wastes that escape into the environment most often impact the public through air and water contamination. An effective strategy for managing hazardous wastes should encourage waste minimization, recycling, and reuse over disposal. Developing countries are especially in need of low-cost technologies for managing hazardous wastes.

Superfund research program--accomplishments and future opportunities.

This special issue of the International Journal of Hygiene and Environmental Health provides extensive background on the Superfund programs, findings of specific research studies and future directions. Three federal agencies are leading the effort in this program. They are the National Institute of Environmental Health Sciences, U.S. Environmental Protection Agency and the Agency for Toxic Substances and Disease Registry. As a result of their collaboration, a comprehensive program has been developed that ranges from basic to applied research with the aim of improving public health services and protection. This paper highlights the research within areas of toxicological investigation, exposure assessment, risk evaluation and engaging communities. Each of the agencies has developed strategies and initiatives to enhance the effectiveness of the Superfund research program. The continuation of research will contribute significantly towards achieving the Healthy People 2010 goals that have been set for the United States.

Future directions of environmental public health research: ATSDR's 2002-2010 agenda for six priority focus areas.

Additional research on human exposures to hazardous substances in community settings and resultant adverse health effects is needed to fill an extensive number of information gaps. For example, information is needed to answer specific public health questions about the toxic effects of specific chemicals, who has been exposed, what the health risks might be, and what interventions are effective. The Agency for Toxic Substances and Disease Registry (ATSDR) is the principal federal agency responsible for addressing issues of public health concerning the human health risks associated with hazardous waste sites and unplanned releases of hazardous substances into the environment. Research is a critical component in how effectively the agency can identify persons exposed, determine health risks, and intervene to reduce exposures and adverse health outcomes. ATSDR has recently developed an agenda for public health environmental research for 2002-2010, divided into the following six research focus areas: exposure assessment; chemical mixtures; susceptible populations; community and tribal involvement; evaluation and surveillance of health effects; and health promotion and intervention. This article discusses the agenda's development, the research issues within each of the six focus areas, and preliminary implementation plans.

Overview of international environmental health.

Ultimately, the health and quality of life of all human beings depend upon the environment and ecosystems to which we are directly and indirectly connected. The papers in this special edition address a number of the critical environmental health issues on which U.S. government agencies and their collaborating partners are engaged internationally. The agencies are members of the International Environmental Health Subcommittee, chaired by the U.S. Department of Health and Human Services. The activities described span the range from global policy to country-level field activities. While environmental factors related to infectious disease dominate the global burden of environmentally-related disease, acute and chronic exposures to chemicals are increasingly important public health issues at the local, national, and regional levels; arsenic in drinking water is a good example. Intersectoral action involving governments (at all levels), the private sector, and civil society working together in partnership is absolutely critical to sustainably resolving the problems touched on this overview and meeting the environmental health challenges of the twenty-first century.

A global approach to childhood lead poisoning prevention.

Childhood lead poisoning is an important, preventable environmental disease affecting millions of children around the world. The effects of lead are well known and range from delayed and adversely affected neurodevelopment to severe health outcomes including seizures, coma, and death. This article reviews the childhood effects of lead poisoning, the approach being taken to the problem in the United States, and the obstacles faced by developing nations in dealing with lead exposure. The United States has attacked the childhood lead poisoning problem by attempting to eliminate sources of exposure, including gasoline, solder in water pipes and cans, and industrial emissions. These actions have resulted in a dramatic reduction in the number of children with elevated blood lead levels in the United States over the last two decades. However, many developing countries are just beginning to address the problem. Successful efforts will need to incorporate epidemiologic methods, source identification, enforced regulations, and a long-term government commitment to eliminating lead as a threat to the next generation of children.