Sean Whitfield - NURS 4530 Active Learning Guide Module 3, Epi, Environment, Surviellance, Foodborne Disease PDF

ALG Module 3: Epidemiology, Environmental Health, Surveillance, and Foodborne Illness (2 weeks) Module 3 Introduction: “Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, and social and psychological proble...

ALG Module 3: Epidemiology, Environmental Health, Surveillance, and Foodborne Illness (2 weeks) Module 3 Introduction: “Environmental health comprises those aspects of human health, including quality of life, that are determined by physical, chemical, biological, and social and psychological problems in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations” (WHO). This summary from the WHO captures why nurses need to learn about how the environment effects health. For example, crowded conditions for humans and animals increase infectious disease transmission, environments that support mosquitoes and ticks increase the risk of vector-borne illness, air pollution can trigger asthma, materials such as asbestos in buildings are known carcinogens and environmental tobacco exposure can cause illness even if the person never smoked. You will see ties to disaster management, for example when a tornado hits an older neighborhood you have to be concerned about lead and asbestos exposure from damaged homes. The American Nurses Association calls for all nurses to understand basic environmental health concepts. Florence Nightingale and Lillian Wald emphasized the importance of improving environments to improve health outcomes and that need continues to the present. All nurses use epidemiology! How it is determined when population-based screenings are done and who needs to be screened? How did we learn that cigarette smoking could cause lung cancer? Epidemiology! Recently, we watched the process of surveillance very publicly during the early stage of the Covid-19 pandemic. Surveillance is part of epidemiology. You will watch a CNN video from a series called The Eighties about the beginning of the AIDS pandemic. The video takes you through the first stages of an outbreak investigation for one of the deadliest pandemics. Foodborne illness continues to cause illness and death in the US each year and while some issues with food safety were solved with inventions such as pasteurization and refrigeration, others like mass production of food have caused other concerns. You will also practice foodborne illness outbreak investigation. Waterborne illnesses have been reduced by having clean, safe municipal water systems with samples tested regularly by local health departments to ensure the water remains safe to drink. However, there are still areas of water safety that need to be monitored and addressed. Outcomes: After you complete this module, you will be able to:  Explain the relationship between the environment, health, and disease.  Identify the knowledge of environmental health needed by nurses in public health and other settings.  Describe legislative and regulatory policies that have influenced the impact of the environment on health and disease patterns.  Incorporate environmental assessment into practice.  Define epidemiology and the major epidemiological terms and concepts.  Explain the relationship of the natural life history of disease to the levels of prevention in designing and implementing community interventions.  Interpret basic epidemiologic measures and findings.  Describe what makes an effective screening program.  Describe the role of surveillance systems in public health.  Describe the types of surveillance systems and the uses of each type.  Identify sources of data used in outbreak investigation.  Identify how nurses are involved in surveillance and outbreak investigation.   Identify the most common and the most virulent food-borne illnesses.  Explain the causes of food-borne illnesses.  Explain the control of food-borne illness at the family, local, and systems levels.  Explain public health's role in safe drinking water.  Identify the major water-borne illnesses in the US. Reading Assignment: Nies & McEwen Ch. 5 Epidemiology; Ch. 14 Environmental Health Also view the videos in the ALG to help answer questions and watch the third episode, The Fight Against AIDS, from the CNN documentary series, The Eighties. You will need to purchase through your chosen streaming platform. The following link provides Prime access, however, the episode may also be purchased through VUDULinks to an external site., YouTubeLinks to an external site., or other sites.  S1 E3 - The Fight Against AidsLinks to an external site. Epidemiology Epidemiology: Epi – upon; demos – people; logos – thought. The textbook defines epidemiology as “the study of the occurrence and distribution of health-related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems”. It is systematic study of populations to investigate how the disease is distributed. It is interdisciplinary. What professionals work in epidemiology?  Epidemiologist  Biostatisticians  Physicians  Nurses  Environmental Health Workers  Policy Makers Answers who, what, where, when, why, and how? Describe what this means. Who. Population impacted by the specific health condition or disease. What. The health condition or disease being studied. Where. The populations geographic location. When. The time duration and frame when the disease occurs. Why. The determining factors that causes the health issue. How. The means that the health condition or disease spreads or is controlled. Originally used in infectious disease, now includes chronic disease, accidents, occupational injury, etc. At what timeframe did the leading causes of mortality change from infectious disease to chronic illnesses? Living conditions improved and as a result decreased incidents of infectious disease. Advancements in antibiotics/vaccinations controlled the spread of infectious disease. Increased living age, chronic illnesses moved to the forefront. Ex, heart disease and cancer. What happened that this shift occurred? The industrialization of our culture and urban sprawl has caused the increase in sedentary lifestyle and increased exposure to carcinogens and pollution. What is mortality? The ratio of deaths in an area to the population of that area; expressed per 1000 per year. Morbidity? The rate of incidence of a disease. The purpose is to promote wellness, prevent disease, prevent premature death and disability. How might the use of epidemiology help identify priorities for health programs in a community?  Assess/Monitor patterns of disease  Recognizing at risk populations  Evaluation of current programs effectiveness  Allocating resources to areas of need What does Years of Potential Life Lost (YPLL) mean and how is it used in epidemiology? Years of potential life lost or potential years of life lost is an estimate of the average years a person would have lived if they had not died prematurely. It is, therefore, a measure of premature mortality. As an alternative to death rates, it is a method that gives more weight to deaths that occur among younger people Terms to report relative frequency: What does each one mean and give an example of use. Types of Disease Definition Endemic Diseases that are always present in a population (e.g., colds and pneumonia) Epidemic Diseases that are not always present in a population but flare up on occasion (e.g., diphtheria and measles) Pandemic The existence of disease in a large proportion of the population: a global epidemic (e.g., human immunodeficiency virus, acquired immunodeficiency syndrome, and annual outbreaks of influenza type A) Sporadic A disease that is irregular in occurrence within a particular population (e.g., rabies) Review John Snow’s cholera investigation in the Nies & McEwen text. Think though how epidemiology helped solve and control the outbreak. Descriptive epidemiology describes the occurrence of disease in terms of person, place, and? Time Analytic epidemiology focuses on? The associations and causes. The why and how of disease spread and distribution. Focusing on identifying the risk factors and to determine why and how a disease will occur in a population. Ecological approach is the broad consideration of many levels of potential determinants. Looking at multiple causation instead of a single cause, “a web of causation” of more complex relationships and interactions among several factors that lead to disease. Review Fig 5.3 in the text. Social epidemiology looks at social, economic, social inequalities, social determinants of health, environmental factors including data related to neighborhoods, etc. Why is this useful in explaining distribution of disease? This method assist the epidemiologist explain how factors in society can contribute to the distribution and spread of disease. Example, low socioeconomic status can limit access to healthcare, increased stress, impaired living condition can increase a risk in disease. Review your basic biostatistics know proportion, rate, risk, etc. Biostatistics Proportion Proportions or fractions in which the numerator is the number of events occurring in a specified period. The denominator consists of those in the population at the specified time period (e.g., per day, per week, or per year), frequently drawing on demographic data from the U.S. census. Rate Rates are arithmetic expressions that help practitioners consider a count of an event relative to the size of the population from which it is extracted (e.g., the population at  risk). Risk Risk factors are variables that increase the rate of disease in people who have them (e.g., a genetic predisposition) or in people exposed to them (e.g., an infectious agent or a diet high in saturated fat). Rate Calculations Rate Incidence Rate Prevalence Rate Number of health events in a Number of new casew or events Number of existing cases in specific period divided by occuring in the population in a population at specific point in Population in same area in same specific period divided by time divided by Population at specific period Population at risk during same same specified point in time then specific specified period then multiplied by 1000 multiplied by 1000 Age Specific Rate PMR Number of cases in specific age Number of deaths resulting from category in population at specific cause in a specified specified time divided by period divided by total number Population in the same age of deaths in same time period category at the same specified then multiplied by 1000 time then multiplied by 1000 Morbidity Rates Crude Rates Specific Rates Incidence Rate Crude Death Rate Infant Mortality Rate Number of new cases in a given Number of deaths in a year Number of deaths among time period divided by divided by Total population size children < 1 year of age reported population at risk in the same multiplied by 100,000 during a given time period period multiplied by 10000 divided by Number of live births 1720/200,000 = 0.0086 reported during the same time 75/(4000-250 old cases) = 0.02 0.0086 × 100,000 = 860 per period multiplied by 1000 0.02 × 1000 = 20 per 1000 per 100,000 per year 300/45000 = 0.00666 × 1000 = time period 6.66 per 1000 live births Prevalence Rate Crude Birth Rate Fertility Rate  Number of births in a year divided by Total population size Number of existing cases divided Number of live births divided by multiplied by 100,000 by total population multiplied by Number of women aged 15-44 1000 2900/200,000 = 0.0145 years multiplied by 1000 250/4000 = 0.0625 0.0145 × 100,000 = 1450 per 35,000/500,000 = 0.07 per 100,000 per year women aged 15-44.0625 × 1000 = 62.5 per 1000.07 × 1000 = 70 per 1000 women aged 15–44 years When looking at data the rates of conditions are often adjusted. What does this mean? The information has been changed/modified to focus or control for certain inputs, usually age, to make unbiased comparisons between two populations. What is the purpose of using age-adjusted data? Enables epidemiologists to contrast rates of disease over populations with a different age distribution. This will offer a more precise visualization, graph distribution, on if a particular population is at an increased risk for a specific disease or if the reason for the delta is based on age variation. Define incidence: The rate or extent of occurrence or effect. What is relative risk? The relative risk or risk ratio is the ratio of the probability of an outcome in an exposed group to the probability of an outcome in an unexposed group. The relative risk is calculated by dividing the incidence rate of disease in the exposed population by the incidence rate of disease in the nonexposed population. Prevalence proportion? Prevalence, sometimes referred to as prevalence rate, is the proportion of persons in a population who have a particular disease or attribute at a specified point in time or over a specified period of time. Prevalence differs from incidence in that prevalence includes all cases, both new and preexisting, in the population at the specified time, whereas incidence is limited to new cases only. prevalence In a survey of 1,150 women who gave birth in Maine in 2000, a total of 468 reported taking a multivitamin at least 4 times a week during the month before becoming pregnant. Calculate the prevalence of frequent multivitamin use in this group. Numerator = 468 multivitamin users Denominator = 1,150 women Prevalence = (468 ⁄ 1,150) × 100 = 0.407 × 100 = 40.7% These are important terms to understand how much a condition is affecting the population. In addition to the textbook, this video, Incidence vs Prevalence by Medmastery may be helpful to you https://www.youtube.com/watch?v=XXJl2C1PxTQ The attack rate is the proportion of people exposed to an agent who do what? Develop the disease. Define case fatality rate: In epidemiology, case fatality rate – or sometimes more accurately case- fatality risk – is the proportion of people who have been diagnosed with a certain disease and end up dying of it. CFR in % = Number of deaths from disease divided by Number of confirmed cases of disease then multiplied by 100 Epidemiological triangle: Agents – Hosts -Environments Look at Table 5.1. Give an example of a disease using the Epi triangle and then how it could be used to prevent the disease: The epidemiological triangle is the relationship between the agent, host and the environment. The epi triangle aids the epidemiologist comprehend how diseases are transmitted and how to prevent them. Disease Malaria Agent Plasmodium Parasite Host Humans Environment Stagnant water where mosquitoes breed Prevention Control the environment by removing the stagnant, standing water. Apply insect repellent to population, offer antimalarial medications to population. The Natural Life History of any disease is the course of a disease from onset to resolution or death. Think through the natural life history of “the common cold” vs. influenza. Use the following terms to describe a cold. Interventions for each stage can be addressed using the Levels of Prevention.  Pre-pathogenesis and pathogenesis Exposure – incubation – symptomatic – recovery or death Latent period – infectious period Stage Description Intervention Pre-pathogenesis In the pre-pathogenic period, Hand hygiene. Contact avoidance with sick the disease originates, but the individuals. Strengthen immune system by patient does not yet present Good nutrition, exercise and rest. clinical symptoms or changes in his/her cells, tissues, or organs. This phase is defined by the host conditions, the disease agent (such as microorganisms and pathogens), and the environment. Pathogenesis The pathogenic period is the Hand hygiene. Avoid touching your face to phase in which there are reduce chance of transmission. changes in the patient's cells, tissues, or organs, but the patient still does not notice any symptoms or signs of disease. Exposure Making contact with the cold Hand hygiene. Avoid touching your face to virus. reduce chance of transmission. Incubation Time duration between Hand hygiene. Avoid touching your face to exposure and manifestation of reduce chance of transmission. signs/symptoms. Infectious period Patient experiencing cold Covering cough and keeping space/distance from (Symptomatic) symptoms. others. Recovery or death This stage will take 7-10 days if Managing signs/symptoms. Complete recovery no complications. before engaging in regular activities of daily living. Latent period Person is infected but not Hand hygiene. Avoid touching your face to showing manifestations of reduce chance of transmission. Covering cough signs/symptoms. and keeping space/distance from others. Screening is a key intervention for secondary prevention. Nurses often participate in screenings or have had screening exams such as a mammogram or a colonoscopy. Population-based screening is for those at risk but not yet symptomatic. If the person is having symptoms they need a diagnostic work-up and screenings are not diagnostic. Population-based screenings are to sort out those who probably have the disease or condition from those who probably do not. Why use the term probably? Probably is used to recognize individuals that are at an increased risk of contracting or developing a condition or disease. See the US Preventative Services Task Force (USPSTF) site https://www.uspreventiveservicestaskforce.org/uspstf/ at the bottom of the home page click on Grade Definitions. What are the suggestions for practice for Grade A or B? For C? For D? What does an “I” statement mean? Grade Definition Suggestions for Practice The USPSTF recommends the service. A There is high certainty that the net benefit Offer or provide this service. is substantial. The USPSTF recommends the service. There is high certainty that the net benefit B is moderate or there is moderate Offer or provide this service. certainty that the net benefit is moderate to substantial. The USPSTF recommends selectively offering or providing this service to Offer or provide this service for selected individual patients based on professional C patients depending on individual judgment and patient preferences. There circumstances. is at least moderate certainty that the net benefit is small.  The USPSTF recommends against the service. There is moderate or high D certainty that the service has no net Discourage the use of this service. benefit or that the harms outweigh the benefits. The USPSTF concludes that the current evidence is insufficient to assess the Read the clinical considerations section I balance of benefits and harms of the of USPSTF Recommendation Statement. State service. Evidence is lacking, of poor If the service is offered, patients should ment quality, or conflicting, and the balance of understand the uncertainty about the benefits and harms cannot be balance of benefits and harms. determined. The USPSTF contributes to preventative care by reviewing available research on the effectiveness of screening for disease outcomes. Now look up the recommendations for colon cancer screening. Summarize the recommendations here: Colon cancer screenings are recommended to be scheduled yearly for the ages of 45 – 75. The method of diagnostic testing can impact the frequency. Fecal immunochemical testing/colonoscopy can occur once every 10 years. To continue to test after the age of 75 can be determined individually based on the overall previous screenings and overall health. Next, review the American Cancer Society screening recommendations for colon cancer https://www.cancer.org/cancer/screening/get-screened.html What are the differences in recommendations? The main difference in the recommendations for colorectal screening is corresponding to the age the testing has started and the range of diagnostic tests available.  How will you educate the public regarding colorectal cancer screening?  Begin testing at the age of 45.  Variety of methods of teaching. Invasive/Noninvasive.  Inform about the increased risk of incidence of colorectal cancer.  Individualized diagnostic based on overall health. When setting up population screenings the nurse should be aware of how good a test or screening tool is. This is done by looking at the reliability and validity of the test or tool. A test with good reliability would have consistent and repeatable results. A valid test provides accurate results measured by sensitivity and specificity. Sensitivity is how accurately a test identifies those with a condition, a true positive, or simply – if the person has the disease the test will be positive. Specificity is how accurately a test identifies those without a condition, true negatives, or if the person does not have the disease the test will be negative. Ideally, a test would be what percent sensitive? 100% And what percent specific? 100% Here’s a video to help, Sensitivity and Specificity simplified https://www.youtube.com/watch? v=psELBu7muNY Optional video, Advanced Sensitivity & Specificity Concepts by Medmastery https://www.youtube.com/watch?v=zhIaR8S0WNs Rarely are tests or tools 100% accurate so it is important to understand how to interpret results that are less than perfect. Define a false positive. A result of a test that shows as present something that is absent. Type I error. Define a false negative. A result of a test that shows as absent something that is present. Type II error. Read and reread this section of the book! Positive predictive value and negative predictive value are affected by the prevalence of disease in the? At risk population. Let’s look at flu tests because those are commonly used in clinics and many of us have had this test. Read the page on the CDC site: https://www.cdc.gov/flu/professionals/diagnosis/overview-testing- methods.htm#:~:text=Most%20of%20the%20rapid%20influenza,improved%20accuracy%2C%20includin g%20higher%20sensitivity. What are factors that affect the accuracy of this test? Timing of the test. Tests administered at the beginning of manifestation of signs and symptoms, as the viral load is higher, those administered tests have an increased rate of accuracy. Sample quality. Poorly collected samples can impact the results of the test, causing the false negatives. Prevalence of Influenza. The accuracy can be affected by if it is flu season or not. Type of test. Each test has different specificity and sensitivities. Most of the rapid influenza diagnostic test done in clinics are how sensitive? 50% – 70% This means what? Lower specificity have higher false negatives. Most have what percent specificity? 90 – 95% What does this mean? Higher specificity have fewer false positives. When interpreting a flu test it should be done in the context of? Clinical manifestations of signs and symptoms. Viral culture results are too slow for clinical care of influenza, so why are they important to the epidemiological study of influenza? They aid in the identifying and characterizing the virus. Help to identify new strains and can assist in assessing/monitoring the distribution and possible mutation of influenza virus. Causality is important for nursing to understand because often a single study that might show a result and another study have the opposite result. This can lead to misinterpretation of how to use the study to inform practice. A common phrase is ‘correlation does not equal causation’. Carefully review Box 13.3. BOX 13.3 Overcoming Language Barriers When an Interpreter is Not Available The nurse should be polite and formal. The nurse should greet the client using his or her last or complete name. The nurse should gesture to himself or herself and say his or her name. The nurse should offer a handshake, nod, or smile. The nurse should proceed in an unhurried manner. The nurse should pay attention to efforts by the client or family to communicate. The nurse should speak in a low, moderate voice. The nurse should remember that he or she may have a tendency to raise the volume and pitch of his or her voice when the listener appears not to understand, and the listener may perceive that the nurse is shouting or angry. The nurse should use words that he or she may know in the client's language. Doing so indicates that the nurse is aware of and respects the client's culture. The nurse should use simple words, such as “pain” instead of “discomfort.” The nurse should avoid medical jargon and slang. He or she should avoid using contractions such as “don't,” “can't,” and “won't.” The nurse should use nouns repeatedly instead of pronouns. For example, the nurse should say, “Do you take medicine?” instead of “You have been taking your medicine, haven't you?” The nurse should pantomime words and simple actions while verbalizing them. The nurse should give instructions in the proper sequence. For example, he or she should say, “First, wash the bottle. Second, rinse the bottle,” instead of “Before you rinse the bottle, sterilize it.”  The nurse should discuss one topic at a time. He or she should avoid use of conjunctions. For example, the nurse should ask, “Are you cold [while pantomiming]?” and then “Are you in pain?” instead of, “Are you cold and in pain?” The nurse should determine whether the client understands by having the client repeat instructions, demonstrate the procedure, or act out the meaning. The nurse should write out several short sentences in English and determine the client's ability to read them. The nurse should try a third language. Many Indo-Chinese people speak French. Europeans often know three or four languages. The nurse should try Latin words or phrases. The nurse should ask who among the client's family and friends could serve as an interpreter. The nurse should obtain phrase books from a library or bookstore, make or purchase flash cards, contact hospitals for a list of interpreters, and use both formal and informal networking to locate suitable interpreters. Summarize the criteria for causality: Criteria for Causality Strength of association Rates of morbidity or mortality must be higher in the exposed group than in the nonexposed group. Relative risk ratios, or odds ratios, and correlation coefficients indicate whether the relationship between the exposure variable and the outcome is causal. For example, epidemiological studies demonstrated a higher relative risk for heart disease among smokers than among nonsmokers. Dose–response relationship An increased exposure to the risk factor causes a concomitant increase in disease rate. Indeed, the risk of heart disease mortality is higher for heavy smokers than for light smokers. Temporally correct Exposure to the causal factor must occur before the effect, or disease. relationship For heart disease, smoking history must precede disease development. Biological plausibility The data must make biological sense and represent a coherent explanation for the relationship. Nicotine and other tobacco-derived chemicals are toxic to the vascular endothelium. In addition to raising low-density lipoprotein and decreasing high-density lipoprotein cholesterol levels, cigarette smoking causes arterial vasoconstriction and platelet reactivity, which contribute to platelet thrombus formation. Consistency with other Varying types of studies in other populations must observe similar studies associations. Numerous studies using different designs have repeatedly supported the relationship between smoking and heart disease. Specificity The exposure variable must be necessary and sufficient to cause disease; there is only one causal factor. Although specificity may be strong causal evidence in the case of infectious disease, this criterion is less important today. Diseases do not have single causes; they have multifactorial origins. Some nurses work as epidemiologists but all nurses use epidemiology! Assessment, case finding, and teaching regarding personal and population risk. To supplement the book discussion of the types of epidemiological studies, watch Types of Studies: Let’s Learn Public Health, Epidemiological Studies Made Easy! https://www.youtube.com/watch?v=Jd3gFT0- C4s Environmental Health Also, see the CDC National Center for Environmental Health https://www.cdc.gov/nceh/ Look at the Healthy People 2030 site https://health.gov/healthypeople/objectives-and-data/browse- objectives/environmental-health Note the major objectives related to environmental health.  Air Quality  Toxins and Waste Management  Climate and Natural Disasters  Water Quality  Homes and Communities 1. Globally what percent of deaths are attributed to environmental factors? 16% When contemplating the effects of the environment as you read the chapter and look through the linked sites, note what all is included with environmental health. Focus of Table 14.1 and 14.2. Table 14.1 Areas of Environmental Health Area Definition Built Buildings, spaces, and products that are created or modified by people; including environment homes, schools, workplaces, parks/recreation areas, greenways, business areas, and transportation systems. Work-related Occupational exposure to environmental hazards that can cause illness or injury. exposure Outdoor air The protectiveness of the atmospheric layers, the risks of severe weather, and the quality purity of the air for breathing purposes. Healthy home The availability, safety, structural strength, cleanliness, and location of shelter; including public facilities and family dwellings. This includes indoor air quality. Water quality The availability of and accessibility to a clean water supply, the mineral content levels, pollution by toxic chemicals, and the presence of pathogenic microorganisms. Food safety The availability, relative costs, variety, safety, and health of animal and plant food sources. Waste The management of waste materials resulting from industrial and municipal management processes, human consumption, and efforts to minimize waste production. Table 14.2 Examples of Environmental Health Problems Area Problems Built Drunk driving environment Secondhand smoke Noise exposure Urban crowding Technological hazards Work-related Asbestos exposure exposure Agricultural accidents Excessive exposure to X-rays Outdoor air Gaseous pollutants quality Greenhouse effect Destruction of the ozone layer Aerial spraying of herbicides and pesticides Acid rain Nuclear facility emissions Healthy home Homelessness Rodent and insect infestation Presence of lead-based paint Sick building syndrome Unsafe neighborhoods Radon gas seepage in homes and schools Water quality Contamination of drinking supply by human waste Oil spills in the world's waterways Pesticide or herbicide infiltration of groundwater Aquifer contamination by industrial pollutants Heavy metal poisoning of fish Food safety Malnutrition Bacterial food poisoning Food adulteration Disruption of food chains by ecosystem destruction Carcinogenic chemical food additives Waste Use of nonbiodegradable plastics management Poorly designed solid-waste dumps Inadequate sewage systems Transport and storage of hazardous waste Illegal industrial dumping Radioactive hazardous wastes The textbook states that the chapter uses critical theory to explore the health of communities in relation to the environment. Applying critical theory is a way of thinking? Yes The critical theory approach used to explore the health effects of the environment raises questions about oppressive situations, involves community members in the definition and what? and facilitates what (?) that reduce health-damaging effects of environments. (p. 265). Critical theory is an approach that raises questions about oppressive situations, involves community members in the definition and solution of problems, and facilitates interventions that reduce health- damaging effects of environments. By applying the nursing process in a critical fashion, nurses can be dynamically involved in the design of interventions that alter the precursors of poor health. The built environment and healthy homes: See above Tables 14.1 and Tables 14.2. 2. True or False – the built environment includes the walkability of the community. True. Indoor air quality – carbon monoxide, lead, asbestos, insects, rodents, pet allergens, volatile organic compounds (VOCs), radon the second leading cause of lung cancer, fragrance, potential endocrine disruption, and other risks, tobacco smoke – see the EPA Indoor Air Quality – VOCs – use the EPA Indoor Air Quality site – note the common VOCs and the possible health effects. https://www.epa.gov/indoor- air-quality-iaq/volatile-organic-compounds-impact-indoor-air-quality#intro 3. Give 2 examples of health issues that can result from poor indoor air quality: Radon → Lung Cancer Mold, 2nd Hand Smoke → Respiratory distress. Asthma. 4. What is environmental justice? Environmental justice or eco-justice, is a social movement to address environmental injustice, which occurs when poor or marginalized communities are harmed by hazardous waste, resource extraction, and other land uses from which they do not benefit. The movement has generated hundreds of studies showing that exposure to environmental harm is inequitably distributed. In discussions of environmental justice, the acronym NIMBY (not in my backyard) is often used. 5. What is meant by NIMBY related to environmental issues? Residents are against particular developments or certain projects in their area, even though they may support that same project in other or general locations. What are some of the increased risks of exposure for those living in vulnerable neighborhoods?  Increased Rate of Cardiovascular Disease  Increased Rate of Respiratory Distress  Increased Impact from Changes in the Climate  Increased Rate of Stroke  Increased Exposure to Hazards Work-related exposures: 6. What are examples of occupational exposures that might cause health problems? Work-Related Exposures Work-related exposures can happen as a result of poor working conditions and can lead to potential injury or illness. Environmental health problems posed by work-related exposures  include such issues as occupational toxic poisoning, machine-operation hazards (e.g., falls, crushing injuries, burns), electrical hazards, repetitive motion injuries, carcinogenic particulate inhalation (e.g., of asbestos, coal dust), and heavy metal poisoning (Centers for Disease Control and Prevention [CDC], 2013; Krieger et al., 2008). Prevention of work-related health problems requires integrated action to improve job safety and the working environment. Occupational and environmental health nurses often collaborate on initiatives to reduce and eliminate work- related exposures, illnesses, and injuries. Nurses can be sure that workers are aware of and know where to access the safety data sheets relevant to their workplace. The U.S. Department of Labor's Occupational Safety and Health Administration (OSHA) (2013) requires chemical manufacturers, distributors, and importers to provide safety data sheets that communicate the hazards of chemical products. 7. The EPA estimates that how many physician diagnosed pesticide poisonings occur each year? The EPA estimates that 10,000 to 20,000 physician-diagnosed pesticide poisonings occur each year among the approximately two million US agricultural workers. Outdoor air quality: 8. The WHO estimates that air pollution contributes to approximately how many premature deaths annually worldwide? WHO estimates that air pollution contributes to approximately seven million premature deaths annually worldwide. 9. Nurses should be aware of the EPA’s Air Quality Index (AQI) and provide education regarding recommendations. What are the groups that should reduce outdoor activity for a particle pollution level of 101- 150? People with heart or lung disease, older adults, and children should reduce prolonged or heavy exertion. 10. How does the environment affect the transmission of infectious diseases vector-borne diseases such as West Nile Virus or Lyme disease? For example, global warming contributed to the entry and propagation of the West Nile virus in the United States (Epstein, 2001) and is suspected in facilitating the rapid spread of the Zika virus (Chan et al., 2016). Higher air and water temperatures facilitate the spread of vectorborne diseases transmitted by mosquitoes (e.g., West Nile virus). As a result, 2012 saw more cases of West Nile virus infection (5387) than any year since 2003, with a higher proportion of deaths (243) (CDC, 2012); however, between 2012 and 2015 there has been an annual consecutive reduction in both the number of cases and deaths related to West Nile Virus (CDC, 2016). Water pollution: Runoff from roads, pesticides on crops, etc. In the US all public water suppliers use EPA’s safe drinking water standards to test the water supply and annual reports are sent to customers. Private wells are not regulated.  11. You are working with a family with a newborn and learn they plan to use powdered formula. You assess that they have well water at home. What additional assessment and education should the nurse consider? Assessments ◦ Water Quality Testing ◦ Water Treatment Systems Education ◦ Safe Water Sources ◦ Proper Formula Prep ◦ Routine Water Testing Human and animal pharmaceutical pollution: the US Geological Service found antibiotics, codeine, 17B- estradiol, acetaminophen, and endocrine-disrupting chemicals in measurable amounts in streams and rivers. 12. What health impacts concern you regarding these findings? Antibiotic Resistance Endocrine Disruption Ecosystem Disruption Physiological Changes in Aquatic lifeforms The Biomonitoring program by the CDC conducts studies to learn what environmental chemicals we are exposed to, and the amount of those chemicals that are in people’s bodies. For most of these, it is still unknown what if any amounts would be considered safe. These large studies help determine this. Many environmental exposures do not harm health until years or decades later. 13. What are some examples of delayed health issues related to environmental exposure? Cancer Neurological Disorders Cardiovascular Disease Respiratory Issues Reproduction Issues. https://www.cdc.gov/biomonitoring/index.html 14. What is biomonitoring? CDC’s National Biomonitoring Program studies the chemicals in our environment —and what happens when we encounter those chemicals. This important research helps us identify chemicals that may be harmful to our health and take steps to reduce potential health risks. https://www.cdc.gov/biomonitoring/videos/What-is-biomonitoring.html 15. Give an example of biomonitoring shaping policies that affect our health? National Health and Nutrition Examination Survey Examples of each category of toxic substances:  Heavy metals or metallic compounds – arsenic, cadmium, chromium, lead, mercury Hydrocarbons – benzene, toluene, ketones, formaldehyde, Irritant gases – ammonia, hydrochloric acid, sulfur dioxide, chlorine Chemical asphyxiants – carbon monoxide, cyanide Pesticides – organophosphates, carbamates, chlorinated hydrocarbons Heavy metal exposures: lead https://www.cdc.gov/lead-prevention/about/index.html and mercury https://www.atsdr.cdc.gov/mercury/index.html 16. What group is most at risk from mercury exposure? Pregnant women, young kids and infants. What is the most common way to be exposed to mercury? Consuming fish, an industrial source, coal fired plant emissions, fluorescent bulbs and thermometers. What are the major health risks from mercury? Nervous system damage, tremors, loss of memory and motor skills impairments, cognitive and motor impairment in children. 17. What group is most at risk for lead exposure? Children under the age of 6. Nervous system development damage. How does exposure often occur? Lead based paint. What are the major health risks from lead? Cognitive impairment, behavioral issues, learning disabilities and damage to nervous system and kidney’s. Toxicology: Toxicology is a field of science that studies the harmful effects of chemicals, substances, or situations can have on people, animals, and the environment https://www.niehs.nih.gov/health/topics/science/toxicology#:~:text=Toxicology%20is%20a%20field%20 of,%2C%20animals%2C%20and%20the%20environment. Determines if or how exposures can harm the health of a person. Think dose, exposure time, and populations at risk. Determines the threshold level or the dose of the substance that will cause an initial toxic response in the body. The poison is in the dose as an old saying goes. 18. How would a nurse assess to determine the dose of exposure? ◦ Origin of exposure ◦ Type of hazard exposure ◦ The route of exposure ◦ Quantity exposed to ◦ Duration of exposure and frequency ◦ Vulnerability of the population or individual ◦ Environment and location Toxic substances can damage cells, organs, disrupt biochemical processes, or enzymes/ hormone systems. Factors such as age, weight, pregnancy, genetics, and medications taken must be considered as well. 19. Children are not just small adults. Review the following article to determine why children have higher risks related to environmental exposure: Summarize the higher risks for children: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982419/ At the beginning of their development Increased intake Behavioral inputs Detoxification systems not as developed Older people may have decreased liver and renal function so clearing the toxic substance from the body may be impaired. A private, non-profit advocacy group called the Environmental Working Group (EWG) produces consumer information about toxic substances found in food and skin care products. One of their more popular releases each year is The Dirty Dozen which is the 12 foods found to retain the most pesticides. They also have a Clean 15 list of which foods retain the least. Most other foods are found between those in the report. https://www.ewg.org/foodnews/dirty-dozen.php https://www.ewg.org/foodnews/full- list.php Keep in mind that pesticides are regulated in the US and it is better to eat fruits and veggies than to avoid them! 20. What are 2 foods you love that are on the dirty dozen list? Blueberries Peaches Here is a link to EWG’s Skin Deep if you’d like to check out the products you use! (optional) https://www.ewg.org/skindeep/ Environmental Assessment: risk for individuals and in populations. Assessment of the potential risks in a community such as a factory, excessive heat, potential storms, old Superfund or Brownfield sites. 21. Be sure to review the assessment on p. 266 and think through what the nurse is looking for in the questions. For example, question #10, why assess the year the patients’ home was built? Take inventory of materials used to build. Was led based paint possibly used during the construction. Environmental Protection Agency’s EnviroFacts – can look up information by zip code, etc. to assess community risks https://enviro.epa.gov/ Geographic Information Systems (GIS) is a newer way to look at environmental data by coding it to a place on Earth. Researchers can use overlaying of the data maps to see potential problems. An example is a geographic data set that notes where children under 10 live and overlaying data that shows the age of the housing stock. A public health nurse could use this to target surveillance and education about lead exposure for example. Another example is GIS being used to study the link between air pollution and ED visits for CV and pulmonary illness. Environmental Health Assessments: From the Agency for Toxic Substances and Disease Registry (ATSDR) and also found in your textbook, the I PREPARE assessment. 22. Fill in what each letter stands for. Note that you should never just record “retired” for work or occupation. Retired from what? In other words, were there exposures? How much (dose)? For how long? I—Investigate Potential Exposures P—Present Work R—Residence E—Environmental Concerns P—Past Work A—Activities R—Referrals and Resources E—Educate Community Environmental Assessment will be part of your community assessment project. In the Windshield Survey, what did you see? Smokestacks on factories/ large animal feeding facilities? Green spaces? Walkable communities? Grocery stores? Crowded spaces? Noise? The “built environment’ is part of the assessment. What are other areas to assess? (not to answer, just making the link to your project) Risk communication is important. Public health professionals need to communicate the right information, to the right people, at the right time. Not all risks are equal so it is important to understand the risk posed by environmental exposure from what is known. Is the substance known to be non-life- threatening or life-threatening? Or to cause serious health problems such as birth defects, or reversible, less serious problems such as a cough or headache? 23. What are some factors that are more likely to create a sense of panic in a population? Reduced informatiom Fast spread of disease (Covid) Visible obvious severity Media coverage Perceived risk to self Inconsistent reporting Epidemiology is the science that shows the strength of the association between exposures and health effects. It is difficult to have control groups for environmental exposures so studies of large numbers are important! The epidemiological triangle is a visual reminder of how important the environment is in epidemiology. Agent Host Environment Surveillance and Outbreak Investigation Reading: Nies & McEwen Ch. 5, pp. 85-7, and Case Study pp. 93-94 Ch. 14, pp. 274 – 275 Start by watching this video, Let’s Learn Public Health, Surveillance: https://www.youtube.com/watch? v=3IpE8dE4cVc Also use this video, A Guide to Outbreak Investigation to answer questions below https://www.youtube.com/watch?v=kUlKRIMxpZQ&t=453s Nurses have a significant role in the interdisciplinary processes of surveillance and outbreak investigation. Surveillance remains a critical intervention to control infectious diseases. In 1901, the US began requiring reporting cases of diseases. The National Office of Vital Statistics began publishing weekly mortality and morbidity statistics in 1949, where can you find the MMWR, the Morbidity and Mortality Weekly Report today? https://www.cdc.gov/mmwr/index.html What are the purposes of surveillance and what can it help facilitate? Assess/Monitor trends in disease, outbreaks, directing public health actions, and assessing interventions. Facilitates early detection, interventions, prevention strategies and resource distribution and allocation. What is cluster detection and how is it used by nurses in the community? Cluster detection is used to recognize patterns of illness, to aid community nurses to examine and explore potential outbreaks and roll out interventions of control. What is a notifiable disease? A notifiable disease is any disease that is required by law to be reported to government authorities. The collation of information allows the authorities to monitor the disease, and provides early warning of possible outbreaks. In the case of livestock diseases, there may also be the legal requirement to kill the infected livestock upon notification. Locate the National Notifiable Diseases Surveillance System (NNDSS). https://www.cdc.gov/nndss/index.html Go to the CDC homepage for this surveillance system, the NNDSS site and click on the Data and Statistics tab. Then the Infectious Disease Tables. Under Weekly Tables click on the WONDER Weekly Tables of Infectious Diseases, In 2024 so far how many cases of Chikungunya disease? 102 List the 3 states with the highest number of cases in 2024: Texas North Carolina Pennsylvania So, what is Chikungunya disease? Describe using the Natural Life History. Chikungunya is an infection caused by the Chikungunya virus. The disease was first identified in 1952 in Tanzania and named based on the Kimakonde words for "to become contorted". Symptoms include fever and joint pain. These typically occur two to twelve days after exposure. Other symptoms may include headache, muscle pain, joint swelling, and a rash. What is a case definition and why is it important? A set of criteria to create a standard for classifying if a person has a specific syndrome, disease or health condition. What is the difference between a probable or confirmed case? Probable case. A case that meets the clinical manifestation and there is a link to confirmed case or known outbreak, but does not have a lab value to confirm. Confirmed case. A suspected case that fulfills bot the clinical standard and has a laboratory value that confirms the disease. Match the types of surveillance systems to the descriptions: Passive __C__ a. data from blogs and social media for example Active _D___ b. data from select institutions or groups Sentinel __B__ c. routinely reported data, notifiable by law, birth and death certificates, etc. Rumor _A___ d. cases sought out, used in outbreaks, serosurveillance, health survey Syndromic _E___ e. reporting of nonspecific symptoms such as fever or GI symptoms Summarize what signals the need to investigate a possible outbreak: Sudden increase in cases of particular disease Increased severity of clinical manifestations Affected specific group or populations Outline the steps of an outbreak investigation: Verify outbreak Define cases Gather data Examine data Form hypothesis Test hypothesis Roll out interventions Communicate results Not in the book but see if you can find the answer. Now that we have less testing and certainly less reportable testing because people are using home tests if they suspect they have Covid-19. What surveillance system is currently being used to monitor for an uptick in cases in a population? National Wastewater Surveillance System Now use the next section to take notes while watching the documentary – this is an example of outbreak investigation and how all aspects of the environment, including the social environment impact health. (note – this video is not appropriate for young children) CNN video – The Eighties – The AIDs Crisis AIDS-defining illnesses first identified: 1. Pneumocystis Pneumonia (PCP) 2. Kaposi’s Sarcoma 3. In the first news story shown in this video in 1981, there were _5____ known AIDS cases. …then there were _2_____ deaths. 4. Where in the US were most of the first cases identified? __Los Angeles_________________ _________________ 5. What type of surveillance was being used early in process of identifying this new disease? Passive surveillance 6. Who? Primarily young gay men What? Odd cases of pneumonia and cancer Where? Los Angeles, New York, and San Francisco When? Early 1980s Why? Initially identified due to “clusters” of infections and rare cancers. 7. Those at risk were found to be _homosexual men___________________________, __IV drug users_________________________, and those with ___Hemophiliacs and blood transfusion patients_______________________________. 8. Why in these groups? Section of the population at increased risk due to behavior and medial procedures that are at higher risk for exposure to AIDS. 9. AIDS began in __Central Africa____________________, spread to __Haiti____________________ and then to the US. 10. Homosexuals were restricted from __Donating blood______________________ _______________________. 11. 1984___ the probable cause of AIDS was found to be _HIV Human Immunodeficiency Virus___________. 12. HIV attacks _CD4_____ cells, having a devasting effect on the _Immune_________________ system. 13. 1985 __20,000__________________ cases. 14. How did Ryan White get an HIV infection? _Contaminated blood transfusion_______________________________________ 15. C. Everett Koop was the _Surgeon General__________________ ___________________ during the early years of the AIDS epidemic. What did he insist needed to be done? Widespread education to the public about AIDS and HIV prevention. 16. The first drug approved to treat HIV was _AZT (Zidovudine)____, and that was in 1987____. It didn’t cure HIV but it did stop viral _replication____________________. 17. 1987____ the AIDS quilt was first displayed in Washington, DC. 18. 1989_____ Act Up hold a protest at the _Food and Drug Administration_______. Why? To request fast track approval for AIDS medications. 19. Ryan White died at age 18_____ in 1990____. 20. By 1990 at least 100,000_________________ people were infected in the US and _8 million________________in the world. 21. Were there any curative medications a decade into the pandemic? No. Only treatments to help manage the disease. 22. How did public response change from 1981 to 1990? Started out with stigma, fear and discrimination. Due to widespread education, over time the awareness, and public health initiatives, increased understanding and increased fundraising for research and treatment. Foodborne illness Local news story, the HD and Foodborne Illness https://www.youtube.com/watch?v=YHayGPBxt2Q CDC estimates how many people in the US get sick from a foodborne illness each year? 48 million And how many die from a foodborne illness in the US each year? 3000 Large outbreaks can originate in a field, a slaughterhouse, a food processing plant, or anywhere along the supply chain. Local outbreaks can happen in a restaurant kitchen and people can get a foodborne illness at home from something such as leaving leftovers unrefrigerated too long. https://www.cdc.gov/foodborneburden/index.html What is important to teach in the home regarding food safety, especially for those who are at increased risk? Cleanliness, hand hygiene, clean utensils and surfaces. Separate cutting boards. Cook food to proper temperature (internal). Refrigerate leftovers within two hours. What are ways patients can be educated to reduce risks in the home when preparing or serving food? Patient education should include the importance of proper/correct food handling. At risk groups should avoid intake of raw/undercooked foods. What patient groups are most likely to be severely affected by foodborne illness? https://www.cdc.gov/foodsafety/index.html Pregnant women Older adults Young children People with suppressed immune systems Open the CDC Food Safety page tab for Foodborne Germs and Illnesses. https://www.cdc.gov/food-safety/about/?CDC_AAref_Val=https://www.cdc.gov/foodsafety/ foodborne-germs.html Fill in the table below of the most common food borne illnesses (note their are many other sources of foodborne illness, see the full list on the CDC site), and the ones most likely to cause hospitalizations and deaths. Top 5 Germs Incubation Notable signs and Duration of Most common Causing: period symptoms and potential illness associated complications/populations foods at most risk Illnesses Norovirus (also top 12-48 Nausea, vomiting, 1-3 days Leafy greens, 5 for hours diarrhea, stomach cramps. fresh fruits, hospitalizations Fever, headache, body shellfish (like and deaths) aches. oysters), and Populations at Risk: Young ready-to-eat children, elderly, and foods handled immunocompromised by infected individuals. workers Salmonella, non- 6 hours to Diarrhea, fever, 4-7 days Poultry, eggs, typhoidal (also 6 days abdominal cramps. beef, leads to Nausea, vomiting, and unpasteurized hospitalizations headaches. milk, fruits, and deaths) and vegetables Clostridium 6-24 hours Sudden onset of Less than 24 Meats, perfringens abdominal cramps and hours poultry, diarrhea. gravies, Rarely causes fever or stews, or vomiting. foods that are kept warm for long periods Campylobacter 2-5 days Diarrhea (often bloody), 1 week Undercooked (also top 5 for fever, abdominal cramps, poultry, hospitalizations nausea, vomiting contaminated and deaths) water, unpasteurized  milk Staphylococcus 30 minutes Sudden onset of nausea, 1 day Cream-filled aureus to 8 hours vomiting, stomach pastries, cramps, diarrhea sandwiches, salads (tuna, chicken, potato), dairy products Hospitalizations – not included with frequent illnesses Toxoplasma gondii 5-23 days Flu-like symptoms (fever, Weeks to Undercooked (also in the top 5 muscle aches), eye months meat (pork, for deaths) problems. lamb, Severe in pregnant women venison), and immunocompromised contaminated people. water, unwashed fruits/vegetabl es E.coli 0157 1-10 days Severe stomach cramps, 5-10 days Ground beef, diarrhea (often bloody), leafy greens, vomiting raw milk, water contaminated with feces Deaths – not included in other categories Listeria 1-4 weeks Fever, muscle aches, Varies; can Soft cheeses, monocytogenes diarrhea, headache last days to deli meats, weeks unpasteurized milk, smoked seafood Click on the Botulism tab. What foods are commonly associated with botulism? Canned foods not properly preserved. Fermented, smoked or processed meats improperly processed. Homemade fermented foods that do not have proper sterilization What food is concerning for infants and should never be given to a child under 12 months? Honey What are the common symptoms of botulism? Double or blurred vision Drooping eyelids Slurred speech Dysphagia Muscle weakness Paralysis Respiratory failure For local outbreaks of foodborne illness such as from a restaurant, the local and state health departments will handle the investigation. If the same illnesses and history of foods eaten signals a concern in the surveillance systems it will be a regional or national outbreak investigation. This is where you may see recalls reported in the news. Summarize how an outbreak investigation is done for a local outbreak and for a regional or national outbreak. Reporting Epidemiologist data gathering Assessment/Monitoring of envirionment Lab diagnostics Public health interventions https://www.cdc.gov/foodborne-outbreaks/help-solve-outbreaks/?CDC_AAref_Val=https:// www.cdc.gov/foodsafety/outbreaks/basics/help-solve-outbreaks.html https://www.cdc.gov/foodborne-outbreaks/?CDC_AAref_Val=https://www.cdc.gov/foodsafety/ outbreaks/index.html Review the sample investigation forms from the CDC to investigate a listeria outbreak and a standard questionnaire from Minnesota https://www.cdc.gov/listeria/pdf/listeria-initiative-case- report-form-p.pdf Play the CDC game Solve the Outbreak Game to review and apply this information. These are based on cases of foodborne illness investigated by the CDC. The Case of the Conference Blues is an investigation of a multistate outbreak and Midterm Revenge is a local outbreak that occurred on a college campus. https://www.cdc.gov/mobile/applications/sto/web-app.html Waterborne illness – safe drinking water is foundational to public health and providing clean drinking water is one of the biggest public health accomplishments in the US. However, water safety remains an ongoing concern. How many in the US get sick every year from waterborne diseases? 7,000,000 What are the 2 most common illnesses reported? Acute otitis externa and norovirus How many deaths are linked to waterborne illness? 6,600 Look up one of the most common waterborne illness in the US, Giardia and summarize the natural life history of this illness. Parasite with two main stages. Trophozoite Stage. The active motile form that inhabit the small intestines, where they multiply. Cyst Stage. This stage is dormant and infective. This form is excreted in the feces and is able to survive for months in the environment. When digested by a new host can change back into trophozoites stage in the intestines. Then look up Legionnaires’ disease. How is this spread? Spread through droplets. What disease does this cause? Pneumonia https://www.cdc.gov/healthy-water-data/report-name/results.html?CDC_AAref_Val=https:// www.cdc.gov/healthywater/surveillance/burden/findings.html