[Environmental burden of disease in Germany]. / Umweltbedingte Krankheitslasten in Deutschland.

BACKGROUND: Environmental risk factors can have a substantial impact on population health. With the environmental burden of disease (EBD) approach, the health losses attributable to environmental risk factors can be quantified using disability-adjusted life years (DALY). OBJECTIVES: The aim of this article is to present and discuss available EBD estimates with a focus on Germany. MATERIALS: Using current EBD studies, the share of the burden of disease attributable to environmental risk factors globally and DALYs for Germany are presented. Ambient particulate matter (PM), water-related risks and environmental noise are used as examples to emphasize the importance of availability and quality of input data for burden of disease assessments. RESULTS: The share of the global burden of disease attributable to environmental risk factors varies according to the available studies and lies between 13 and 22%. For Germany, EBD estimates are available for 12 environmental risk factors. Most estimates are available for particulate matter in ambient air, however, the estimated burden differs greatly. Nonetheless, according to current knowledge, particulate matter pollution is the environmental risk factor with the highest burden of disease in Germany. CONCLUSIONS: Differences in the estimated burden of disease for the considered risk factors are due to varying underlying assumptions, e. g. for life expectancy or counterfactual value and the input data used.

Biomarkers of exposure in environment-wide association studies - Opportunities to decode the exposome using human biomonitoring data.

BACKGROUND: The European Union's 7th Framework Programme (EU's FP7) project HEALS - Health and Environment-wide Associations based on Large Population Surveys - aims a refinement of the methodology to elucidate the human exposome. Human biomonitoring (HBM) provides a valuable tool for understanding the magnitude of human exposure from all pathways and sources. However, availability of specific biomarkers of exposure (BoE) is limited. OBJECTIVES: The objective was to summarize the availability of BoEs for a broad range of environmental stressors and exposure determinants and corresponding reference and exposure limit values and biomonitoring equivalents useful for unraveling the exposome using the framework of environment-wide association studies (EWAS). METHODS: In a face-to-face group discussion, scope, content, and structure of the HEALS deliverable "Guidelines for appropriate BoE selection for EWAS studies" were determined. An expert-driven, distributed, narrative review process involving around 30 individuals of the HEALS consortium made it possible to include extensive information targeted towards the specific characteristics of various environmental stressors and exposure determinants. From the resulting 265 page report, targeted information about BoE, corresponding reference values (e.g., 95th percentile or measures of central tendency), exposure limit values (e.g., the German HBM I and II values) and biomonitoring equivalents (BEs) were summarized and updated. RESULTS: 64 individual biological, chemical, physical, psychological and social environmental stressors or exposure determinants were included to fulfil the requirements of EWAS. The list of available BoEs is extensive with a number of 135; however, 12 of the stressors and exposure determinants considered do not leave any measurable specific substance in accessible body specimens. Opportunities to estimate the internal exposure stressors not (yet) detectable in human specimens were discussed. CONCLUSIONS: Data about internal exposures are useful to decode the exposome. The paper provides extensive information for EWAS. Information included serves as a guideline - snapshot in time without any claim to comprehensiveness - to interpret HBM data and offers opportunities to collect information about the internal exposure of stressors if no specific BoE is available.

[The Environmental Burden of Disease Concept]. / Das Konzept der umweltbedingten Krankheitslast.

GOAL OF THE STUDY: Environmental risk factors are of great importance for public health with a considerable but often unused potential for prevention. However, knowledge about the complex associations between the environment and health effects is limited for some risk factors. A concept, which is using the existing evidence on associations between the impact of environmental factors and health effects, is the environmental burden of disease (EBD) concept. The aim of this article is to present the quantification method of the EBD concept and to discuss the advantages and its points of criticism. METHODS: The EBD concept combines morbidity and mortality data in a single measure (Disability-Adjusted Life Year, DALY) to enable a comparative description of the burden of disease. Life years are used as measurement unit. The environmental share of the total DALYs is quantified by using the attributable fraction. RESULTS: Despite its increasing application especially in the international context, the method is still criticized, because by summarizing the complex construct of health in one single measurement unit, much important information about quality of life is lost. A further criticism refers to partly arbitrarily set social value choices. Additionally, missing or insufficient data can limit the quality and validity of EBD estimations. CONCLUSION: A scientific discourse is needed to decide to what extent the EBD approach can and should be used in Germany.

Global Burden of Disease of Mercury Used in Artisanal Small-Scale Gold Mining.

BACKGROUND: Artisanal small-scale gold mining (ASGM) is the world's largest anthropogenic source of mercury emission. Gold miners are highly exposed to metallic mercury and suffer occupational mercury intoxication. The global disease burden as a result of this exposure is largely unknown because the informal character of ASGM restricts the availability of reliable data. OBJECTIVE: To estimate the prevalence of occupational mercury intoxication and the disability-adjusted life years (DALYs) attributable to chronic metallic mercury vapor intoxication (CMMVI) among ASGM gold miners globally and in selected countries. METHODS: Estimates of the number of artisanal small-scale gold (ASG) miners were extracted from reviews supplemented by a literature search. Prevalence of moderate CMMVI among miners was determined by compiling a dataset of available studies that assessed frequency of intoxication in gold miners using a standardized diagnostic tool and biomonitoring data on mercury in urine. Severe cases of CMMVI were not included because it was assumed that these persons can no longer be employed as miners. Cases in workers' families and communities were not considered. Years lived with disability as a result of CMMVI among ASG miners were quantified by multiplying the number of prevalent cases of CMMVI by the appropriate disability weight. No deaths are expected to result from CMMVI and therefore years of life lost were not calculated. Disease burden was calculated by multiplying the prevalence rate with the number of miners for each country and the disability weight. Sensitivity analyses were performed using different assumptions on the number of miners and the intoxication prevalence rate. FINDINGS: Globally, 14-19 million workers are employed as ASG miners. Based on human biomonitoring data, between 25% and 33% of these miners-3.3-6.5 million miners globally-suffer from moderate CMMVI. The resulting global burden of disease is estimated to range from 1.22 (uncertainty interval [UI] 0.87-1.61) to 2.39 (UI 1.69-3.14) million DALYs. CONCLUSIONS: This study presents the first global and country-based estimates of disease burden caused by mercury intoxication in ASGM. Data availability and quality limit the results, and the total disease burden is likely undercounted. Despite these limitations, the data clearly indicate that mercury intoxication in ASG miners is a major, largely neglected global health problem.

Disability Weights for Chronic Mercury Intoxication Resulting from Gold Mining Activities: Results from an Online Pairwise Comparisons Survey.

In artisanal small-scale gold mining, mercury is used for gold-extraction, putting miners and nearby residents at risk of chronic metallic mercury vapor intoxication (CMMVI). Burden of disease (BoD) analyses allow the estimation of the public health relevance of CMMVI, but until now there have been no specific CMMVI disability weights (DWs). The objective is to derive DWs for moderate and severe CMMVI. Disease-specific and generic health state descriptions of 18 diseases were used in a pairwise comparison survey. Mercury and BoD experts were invited to participate in an online survey. Data were analyzed using probit regression. Local regression was used to make the DWs comparable to the Global Burden of Disease (GBD) study. Alternative survey (visual analogue scale) and data analyses approaches (linear interpolation) were evaluated in scenario analyses. A total of 105 participants completed the questionnaire. DWs for moderate and severe CMMVI were 0.368 (0.261-0.484) and 0.588 (0.193-0.907), respectively. Scenario analyses resulted in higher mean values. The results are limited by the sample size, group of interviewees, questionnaire extent, and lack of generally accepted health state descriptions. DWs were derived to improve the data basis of mercury-related BoD estimates, providing useful information for policy-making. Integration of the results into the GBD DWs enhances comparability.

Disease profile and health-related quality of life (HRQoL) using the EuroQol (EQ-5D + C) questionnaire for chronic metallic mercury vapor intoxication.

BACKGROUND: Toxic mercury is still being used today for example by workers mining gold, resulting in diverse health symptoms in users and individuals in proximity. A considerable burden of disease (BoD) can be assumed, while previous analyses were limited by data scarcity. Besides limited epidemiological data, neither data about the health-related quality of life (HRQoL) nor about the disease severity (disability weight, DW) is available. The aim of the project was to develop disease profiles of chronic metallic mercury vapor intoxication (CMMVI) by including the HRQoL to improve the data basis for BoD analyses of gold miners exposed to mercury. METHODS: Disease profiles comprising the disease label [a], differentiation into disease stages [b], description of the cause of exposure [c], a list of common symptoms [d], and an assessment of the HRQoL [e] were developed using expert elicitation and literature search. The HRQoL was assessed by experts using the five EuroQol dimensions accompanied by the cognition add-on questionnaire (EQ-5D + C). RESULTS: The ten sources used for the analyses (interview transcript, presentation, and eight literature reviews) identified more than 250 terms describing 85 distinguishable health effects of CMMVI. The analysis revealed 29 common symptoms that were frequently mentioned. Moderate and severe CMMVI cases differ regarding their symptoms and/or symptom severity and HRQoL, resulting in the EQ-5D + C-3L codes 121222 and 233333, respectively. CONCLUSIONS: The profiles should be used to facilitate the ascertainment of CMMVI cases, to compare the HRQoL with other diseases, to derive DWs for improving BoD estimates, and to foster discussions about how to reduce the associated burden.

The burden of chronic mercury intoxication in artisanal small-scale gold mining in Zimbabwe: data availability and preliminary estimates.

BACKGROUND: Artisanal small-scale gold mining (ASGM) is a poverty-driven activity practiced in over 70 countries worldwide. Zimbabwe is amongst the top ten countries using large quantities of mercury to extract gold from ore. This analysis was performed to check data availability and derive a preliminary estimate of disability-adjusted life years (DALYs) due to mercury use in ASGM in Zimbabwe. METHODS: Cases of chronic mercury intoxication were identified following an algorithm using mercury-related health effects and mercury in human specimens. The sample prevalence amongst miners and controls (surveyed by the United Nations Industrial Development Organization in 2004 and the University of Munich in 2006) was determined and extrapolated to the entire population of Zimbabwe. Further epidemiological and demographic data were taken from the literature and missing data modeled with DisMod II to quantify DALYs using the methods from the Global Burden of Disease (GBD) 2004 update published by the World Health Organization (WHO). While there was no disability weight (DW) available indicating the relative disease severity of chronic mercury intoxication, the DW of a comparable disease was assigned by following the criteria 1) chronic condition, 2) triggered by a substance, and 3) causing similar health symptoms. RESULTS: Miners showed a sample prevalence of 72% while controls showed no cases of chronic mercury intoxication. Data availability is very limited why it was necessary to model data and make assumptions about the number of exposed population, the definition of chronic mercury intoxication, DW, and epidemiology. If these assumptions hold, the extrapolation would result in around 95,400 DALYs in Zimbabwe's total population in 2004. CONCLUSIONS: This analysis provides a preliminary quantification of the mercury-related health burden from ASGM based on the limited data available. If the determined assumptions hold, chronic mercury intoxication is likely to have been one of the top 20 hazards for population health in Zimbabwe in 2004 when comparing with more than 130 categories of diseases and injuries quantified in the WHO's GBD 2004 update. Improving data quality would allow more accurate estimates. However, the results highlight the need to reduce a burden which could be entirely avoided.

Mercury exposure in female artisanal small-scale gold miners (ASGM) in Mongolia: An analysis of human biomonitoring (HBM) data from 2008.

BACKGROUND: Many poor in developing countries have turned to artisanal small-scale gold mining (ASGM) in an attempt to improve their situation. However, the mercury used to extract gold from ore is discharged in vaporized form into the environment, where it poses a hazard for human health. METHODS: As part of an environmental epidemiological study in Mongolia-to evaluate the burden of environmental mercury contamination-urine, blood and hair samples were collected from residents of areas with or without mercury contamination. A total of 200 blood, urine and hair samples were analyzed for mercury and divided into three subgroups according to mercury content: (1) occupational exposure (high/medium); (2) environmental exposure (low); and (3) no exposure. Internal mercury distributions of the subgroups were compared using the Kruskal-Wallis and Mann-Whitney U-test. The Chi-square test and likelihood ratio proportion were used to compare the findings with threshold limits. RESULTS: The highest values and greatest differences were seen in the urine samples (p<0.001, Kruskal-Wallis). The occupational group showing the highest exposure with a median mercury level of 4.36µg/l (control group: 0.10µg/l, p<0.001), 7.18µg/g creatinine and 12 results above the threshold limit HBM I (Human Biomonitoring I). Even participants from the low-exposure subgroup showed elevated mercury levels (median 2.88µg/l urine and 2.98µg/g creatinine, p<0.001), with 10 individuals above the HBM I threshold limits. DISCUSSION: The body burden resulting from the use of mercury in artisanal gold mining is high not only in the miners themselves, an increased mercury hazard was also found for inhabitants of mining areas who were not actively involved in mining. Public health support measures are urgently needed to alleviate the situation.

Mercury exposure and children's health.

Acute or chronic mercury exposure can cause adverse effects during any period of development. Mercury is a highly toxic element; there is no known safe level of exposure. Ideally, neither children nor adults should have any mercury in their bodies because it provides no physiological benefit. Prenatal and postnatal mercury exposures occur frequently in many different ways. Pediatricians, nurses, and other health care providers should understand the scope of mercury exposures and health problems among children and be prepared to handle mercury exposures in medical practice. Prevention is the key to reducing mercury poisoning. Mercury exists in different chemical forms: elemental (or metallic), inorganic, and organic (methylmercury and ethyl mercury). Mercury exposure can cause acute and chronic intoxication at low levels of exposure. Mercury is neuro-, nephro-, and immunotoxic. The development of the child in utero and early in life is at particular risk. Mercury is ubiquitous and persistent. Mercury is a global pollutant, bio-accumulating, mainly through the aquatic food chain, resulting in a serious health hazard for children. This article provides an extensive review of mercury exposure and children's health.