Welcome to Module 5 of the Public Health Nurse Orientation Program. This module introduces Human Health Hazards and other Environmental Health Issues.

Welcome to Module 5 of the Public Health Nurse Orientation Program. This module introduces Human Health Hazards and other Environmental Health Issues. I m Rebecca Hovarter, one of the Northeast Regional Public Health Nursing Consultants. This module was written by Timothy Ringhand and Karen Morris, the Western Region Public Health Nursing Consultants and myself in consultation with the other Regional Nursing Consultants and others from the WI Division of Public Health. 1

One of the five required services of a local health department is to provide services to abate and remove human health hazards. In this module we will explore how the services are provided or assured by the local health department. We will identify the statutes that relate to the removal of human health hazards, the resources available, including state and regional consultants, some of the public health intervention that are applied to human health hazard abatement, and what is the public health nurse s role in this mandated service. In addition, we will also provide an overview of some other environmental health issues the public health nurse may encounter. This module will cover four sections: environmental health in Wisconsin, resources, principles, and the public health nurse s role. We ll begin now with Section I: Environmental Health in Wisconsin. 2

After completing this module, participants should be able to: Identify the public health environmental health programs in Wisconsin The definition of a human health hazard is a substance, activity, or condition that is known to have the potential to cause acute or chronic illness, to endanger life, to generate or spread infectious diseases, or otherwise affect the health of the public. Hazards may be chemical, biological, physical, or radiological. To give you a better picture of abatement or removal of human health hazards, we will first explore the area of environmental health in more detail. The field of environmental health encompasses exposures in the home, workplace, or community. While many local health departments have an environmental health section, the public health nurse has a vital role in the policies, procedures, and guidelines that are incorporated into practice. The physical environment is one of the nationally recognized determinants of health. (Source: Wisconsin Assembly Bill 483, March 2008). 3

The first orientation session introduced you to the Public Health Intervention Model. The Intervention Model represents what public health nurses do at the individual/family, community, and systems levels to achieve the goals of public health practice. Throughout this session, we will demonstrate how the model represents what interventions public health nurses use to assure healthy environments in their communities. Environmental health presents many terms that are significant to understanding its prevention and control of hazards. Some of the terms may be new to you, while you may be familiar with others. Refer to this module s reference list for more information on these terms. 4

Wisconsin Statute Chapter 254 directs the local health department regarding the activities of environmental health. It defines the powers and duties of the health officer including the authority to enter private premises, order abatement and placard a building. In addition, the statute directs activities related to toxic substances, radiation protection, recreational sanitation, animal-borne and vector-borne disease control, and lodging and food protection. ASSEMBLY BILL 483, March 2008 The bill authorizes a local health officer who is refused entry by the owner or occupant of a property or premises for which the local health officer has received a complaint or has probable cause to believe a human health hazard exists to seek a special inspection warrant or, if a suspected human health hazard poses an immediate threat, to enter the property or premises without consent or a special inspection warrant. For a human health hazard that is found, the local health officer must notify the owner or occupant and order abatement or removal within a reasonable time period, not to exceed 30 days. If the owner or occupant fails to comply with the order within the time period and if the nature of the human health hazard does not pose an immediate threat, the local health officer shall abate or remove the hazard or contract to have that done or shall report the failure to comply to the attorney for the applicable city, town, village, or county, who may initiate court action to abate. 5

For a human health hazard that is found and that poses an immediate threat to the health of an individual or the public the local health officer must make a good faith effort to notify the owner or occupant, confirm the notice by personal service or by mail to the owner s or occupant s last known address, and must abate or remove the hazard. Failure by the owner to remove a health hazard can result in to a fine of not more than $1,000 or imprisonment for not more than 90 days or both. The Bureau of Environmental and Occupational Health promotes public health through statewide programs to increase public awareness of environmental and occupational health hazards and disease and works to prevent and control exposure to environmental and occupational health hazards. Information regarding environmental health issues can be found on the Environmental Health Resources web site. The Bureau provides tracking of environmental and occupational illness, consultation to employers, local public health agencies and the public, and promotes risk reduction through assessment, evaluation and control of environmental and occupational hazards. The Bureau also regulates and licenses restaurants, lodging and recreational facilities, x-ray equipment, radioactive materials and devices and certifies lead and asbestos workers, and food managers. The Bureau of Environmental and 6

Occupational Health has four sections: Health Hazard Evaluation Section, Lead and Asbestos Section, Food Safety and Recreational Licensing Section and the Radiation Protection Section. Source: http://dhfs.wisconsin.gov/eh/ We ll now look at II: Environmental Health Resources. After completing this section, participants should be able to: Identify environmental health resources available at the local, state, and national levels. 7

The Division of Public Health Bureau of Environmental and Occupational Health website has many environmental health resources available to assist local health departments and tribes address environmental health issues. In addition, the site also has many excellent consumer information resources. Later in this module, we will take a closer look at: asthma, disasters, human health hazards, lead poisoning, and food safety. However, you may want to explore the environmental health resource website for information about the other subjects listed on the slide. Several other state and federal agencies are also excellent resources for various environmental health resources. You are encouraged to explore these resources after the presentation. The Health Hazard Evaluation Section tracks environmental and occupational diseases and conditions, performs assessment of uncontrolled hazardous waste sites, provides technical support on indoor air quality, asthma and other environmental issues, conducts research, and provides information regarding the health risks associated with sports fish consumption. Toxicologists within the Section prepare recommendations for groundwater and ambient air quality standards. 8

The Wisconsin Childhood Lead Poisoning Prevention Program and the Adult Blood Lead Surveillance Program track cases of childhood and adult lead poisoning in Wisconsin. Program staff provide consultation and technical assistance to local health departments, prepares policies and guidance on case management and follow-up, and develop strategies to prevent lead poisoning. The Asbestos and Lead Certification Unit maintains a registry of lead-safe and lead-free properties. Unit staff certify lead and asbestos workers and monitor lead and asbestos abatement projects. The Food Safety and Recreational Licensing Section licenses restaurants, lodging facilities, swimming pools and spas, campgrounds, recreational and educational camps and body art practitioners and their facilities. This is accomplished either by local health department of Division of Public Health regional office registered sanitarians. Local and regional registered sanitarians also contract with the Department of Public Instruction to inspect school kitchens and pools. The Section registers environmental health professionals and certifies food managers 9

The Radiation Protection Section inspects and licenses X-ray devices, mammography facilities, radioactive materials, tanning devices. The Section provides technical support regarding the control of indoor radon and provides environmental monitoring around Wisconsin s nuclear energy facilities. The Section maintains emergency response capability for energy or transportation incidents, or potential acts of terrorism involving radioactive materials Section 3 will now look at the principles of environmental health. 10

After completing this section, participants should be able to: Describe the basic principles of environmental health What is environmental health? Environmental health promotes health and quality of life by preventing or controlling those injuries, diseases or deaths that result from interactions between people and their environment (CDC). Environmental health includes public health programs designed to protect the public from health hazards which exist, or could exist in the physical environment. It combines planning, regulatory, educational, informational, consultative, and (when necessary) enforcement strategies. Environmental health professionals, including public health nurses, also help assure that the vulnerable areas of our environment are protected from accidental or intentional contamination. The emergence of many new issues and threats to the public s health establishes the need for an educated and well-prepared environmental health workforce. Some of these issues include assuring safe and secure food and water supplies. New threats include exposures to hazardous chemicals, hazards associated with indoor environments, the emergence of new vector-borne diseases, management of infectious wastes, and threats posed by terrorists. 11

Public health nurses must be able to anticipate, recognize, and respond to these many issues. They must also stay current on the latest information and technology available. The American Public Health Association Public Health Nursing Section developed environmental health principles for public health nurses in 2005. The principles include: Safe and sustainable environments are essential conditions for the public s health. Environmental health is integral to the role and responsibilities of all public health nurses. All public health nurses should possess environmental health knowledge and skills. Environmental health decisions should be grounded in sound science. The Precautionary Principle is a fundamental tenet for all environmental health endeavors. Environmental justice is a right of all populations. Why does public health nursing need principles? Environment and community are intricately connected, so it makes good sense that public health nurses working in communities would seek ways to make environmental health an essential, basic element of practice. The Environmental Health Principles and Recommendations for Public Health Nursing was developed through a collaborative effort of public health nursing and environmental health experts. 12

Public awareness and community involvement are essential in environmental health decision-making. Communities have a right to relevant and timely information for decisions on environmental health. Environmental health approaches should respect diverse values, beliefs, cultures, and circumstances. Collaboration is essential to effectively protect the health of all people from environmental harm. Environmental health advocacy must be rooted in scientific integrity, honesty, respect for all persons, and social justice. Environmental health research addressing the effectiveness and public health impact of nursing interventions should be conducted and disseminated. According to Environmental Health Principles and Recommendations for Public Health Nurses, at this time of local and global environmental concerns, people as individuals and as communities look increasingly to the health care system for information and advice on identifying and reducing health risks associated with the environment, including workplace, exposure to potential hazards, and for diagnosis and treatment of the disease caused by such exposures. Public health nurses often are the first to recognize the environmental hazards and intervene. 13

In previous modules, we discussed the model of disease causation or the epi triangle. It is also applicable in this section as the environment is one corner of the triangle. As a review, the three corners are: Agent. A factor whose presence, excessive presence, or relative presence is essential for the occurrence of a disease. Agents can be physical (temperature), chemical (gases), nutrient ( protein), genetic (transferred through genes), psychological (stress), or biological (bacteria, virus, insects, worms, or protozoa. Host. An individual human in whom an agent produces disease. Environment. All external conditions and influences affecting life of living things. The three main categories of environment are physical, biological, and socioeconomic. For a disease or injury to occur, the basic elements of disease or injury causation and an adequate chain of transmission must be present. Agents, hosts and environment alone are not sufficient to cause a disease or illness. Disease occurs when an outside agent capable of causing the disease or injury meets a host that is vulnerable to the agent in an environment that allows the agent and host to interact. These basic concepts help guide the selection of health strategies to prevent health problems. One of the key jobs for the public health nurses working with environmental health professionals is to intervene at any point in order to reduce the hazard to health. Two more terms that are probably familiar to you but important to review when discussing the epidemiology of illness or injury are portal of entry and portal of exit. Portal of Entry - The means or path by which an agent enters a susceptible host. Portal of Exit - The path by which an agent leaves the reservoir or environment This diagram further illustrates the components of the Chain of Infection, the epi triangle and the components of the disease process. 14

In order to deal with daily assignments public health nurses need to be competent in many areas, including environmental health skills. The three major EH competency areas used widely by the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the American Public Health Association (APHA), and others are shown. These skills are particularly useful in being able to assess risk and damage in an emergency situation. All these skills are relevant to public health nurses in daily work and in emergencies. Assessment skills fall into three main areas: 1. Info gathering is identifying sources of data, and compiling relevant and appropriate information when needed, and perhaps holding the knowledge of where to go to obtain the information. 2. Data analysis includes the ability to analyze data, recognize meaningful test results, interpret results, and present the results in an appropriate way to different types of audiences. 3. Evaluation is determining the effectiveness or performance of procedures, interventions, and programs. 15

The second set of skills is management skills. Management skills are particularly useful in being able to solve problems. Problem solving is developing insight into and appropriate solutions to environmental health problems including economic issues and organizational knowledge Project management prioritizes projects, and plans, implements, and maintains fiscally responsible programs such as computer and other IT programs. Reporting is producing reports to document actions, keep records, and inform appropriate parties. The third set of environmental health skill for all public health workers is communication skills. Education makes use of the public health nurse s front-line role to effectively educate the public on environmental health issues and the rationale for recommendations. Risk communication is the ability to effectively communicate risk and exchange information with colleagues, other practitioners, licensed facilities, policy-makers, interest groups, the media, and the public through public speaking, print and electronic media, and interpersonal relations. Conflict resolution is the ability to facilitate resolution of conflicts within an agency, in the community, and with regulated parties. This includes the ability to handle difficult issues and ensure compliance by reluctant individuals. 16

Marketing is the ability to articulate basic concepts of environmental health and public health and convey an understanding of their value and importance to the public. This includes social marketing, which is a mechanism for changing people's attitudes and behaviors so that a hazard is reduced. Section 4 will look at the public health nurse s role in environmental health. After completing this section, participants should be able to: Recognize the public health nurse s role and skills needed when performing environmental health related activities 17

Public health nurses may assume a variety of roles regarding environmental health in their agencies. We will look briefly at some of the more common environmental health issues the public health nurse may encounter. First we will look at the public health nurse s role in completing a human health hazard investigation in a home. The registered sanitarian in your agency requests you accompany her on a home visit because of a complaint that a mother and her children were living in a house that isn t fit to live in. Where do you start, what are you going to look for? 18

This is a picture, called Messy House from Brooks Publishing, that is used to train home visitors. At first glance the initial thought is Oh no! But as a public health nurse, we do not always see or interpret things the same way the public does. What do you, as a public health nurse, see as assets and what do you see as safety hazards in this home? After studying this picture, public health nurses are always quick to point out the following assets of this household: 1. The family has a home. 2. The family has furniture, in good repair 3. The family has food and money to afford takeout food 4. Since the TV is on, the family has electricity 5. The mom is talking on the phone, so the family has phone service 6. The mom has curlers in her hair and has been ironing clothes, so she has concern about her appearance 19

7. There are not and inappropriate number of pets However, there are some safety hazards noted also. Because this module concentrates on health hazards, that is what we will focus on. Some things noted here as potential hazards include: peeling paint, overflowing garbage, a space heater. And also some safety hazards including: electrical cords, sharp objects within reach of the children, the iron on the ironing board, the child sleeping on the floor next to peeling paint. Inspecting the outside of the house or building is important when investigating reports of human health hazards. A few of the observations include: Bare soil in the yard around the home or common outdoor area Deteriorated paint: Peeling, flaking, chipping, or cracking paint 20

Paint coming loose from surfaces Fences and porches as well as buildings Holes in the walls of the building Rodents or evidence of Standing water Woodpiles near exterior walls Accumulated trash Obvious water damage or wood rot Damaged gutters, downspouts, or other building components Hoarding of animals/pets Inside the home some of the observation will include: Deteriorated paint (peeling, flaking, chipping, cracking paint) Any deterioration, especially dust and chips in the window wells Paint coming loose from painted surfaces Teeth marks on painted or varnished surfaces Cracks or holes in the walls where dust from lead-based paint can fall to the floor Cockroaches or their remains Holes in the walls between the inside and the outside of the building or between rooms Unvented gas oven, clothes dryer, or heater Mold or fungus or similar stains on the walls, carpets, under the sink, outside the shower or around windows Walls that appear wet or newly stained or plaster or drywall that is bulging Rodents or evidence Strong, musty odors Natural gas or sewer gas smell Old or worn out carpeting if in poor condition or extremely dirty Excess garbage, rotting food Hoarding of animals/pets Including feces and urine Check for functioning: Plumbing Potable water Heat (if applicable for the season) 21

Some of the public health nursing interventions used in the human health hazard home investigation include: 1. Disease & Health Event Investigation. The PHN responded to a request to help investigate a possible hazard that may have an impact on human health. The PHN defined the problem, established clear criteria for what constituted an event, considered existing data, generated and analyzed additional data, determined the cause and risk of the problem and communicated an appropriate response. 2. Consultation: The PHN consulted with the environmental health sanitarian about the potential human health hazards 3. Policy Development and enforcement. Depending on the outcome of the investigations, the health department may decide that no health hazards exist, or recommend resolving the hazards through abatement or clean-up, or if the hazards were putting the family in immediate danger, request the family vacate immediately and placard the house. An 18-month toddler received a blood lead test at a well child checkup. The child s capillary result came back as a blood lead level of 15 mcg/dl. The test result was shared with the family by the public health nurse. Because the blood lead level is above 9mcg/dL, they discussed the 22

need to get the child in to see the doctor for a follow-up venous blood lead test to confirm the child s blood lead level. They scheduled a time when the public health nurse and the sanitarian could visit the family s home to do a visual assessment to identify potential lead paint hazards and educate the family about ways to address these potential hazards. During the home assessment, peeling paint was found in the child s bedroom. Instructions for how to fix the peeling paint were given to the family. If the child s venous blood lead test result is greater than 20mcg/dL, the sanitarian will make arrangements with the family to conduct a lead hazard investigation of the family s home and other residences where the child spends a significant amount of time such as a child care center, as required by Wisconsin Statute 254. The state lead program provides this brochure as well as other resources to all local health departments for public health nurses to use with families. Lead exposure in young children can cause reduced IQ and attention span, impaired growth, reading and learning disabilities, hearing loss, and a range of other health and behavioral effects. Most exposures occur in homes or daycares where lead-based paint has deteriorated because of deferred maintenance or where lead hazards have been created through painting or renovation done without using lead-safe work practices. Prevention of lead poisoning can be accomplished by eliminating lead-based paint hazards before children are exposed. Wisconsin's goal is to eliminate this disease by working to make Wisconsin's housing lead-safe, and by improving the detection and treatment of lead poisoning in children. 23

The Wisconsin Division of Public Health, Bureau of Environmental and Occupational Health, the Wisconsin Childhood Lead Poisoning Prevention Program is an excellent resource for the interventions needed for preventing and controlling lead poisoning in children. The accompanying resource to this presentation will direct you to guidelines you need to provide follow up and case management services for a child with suspected lead poisoning as well as define who should be tested, what makes some children more at risk than others including nutrition and socioeconomic status, how children become poisoned and what to do if you are working with children who are lead poisoned. The Lead-Safe Wisconsin website also has resources for professionals and the public. In addition, the Centers for Disease Control and Prevention has essential guidelines for public health nurses who work on lead poisoning prevention and control. 24

The child s venous confirmatory blood lead level was 2 mcg/dl. However, as an astute public health nurse who understands the connection between health and disease and the environment, you don t plan to close the case until further investigation and education is performed. As you recall from the opening scenario, the child s capillary blood lead level was 18 mcg/dl, so the child probably is having some contact with lead dust that should be eliminated. The basic steps for disease and other health event investigation are: Define the problem, correctly identify the disease, at risk for lead poisoning and its source. Establish clear criteria for what constitutes a case. Consider existing data. Generate and analyze data using appropriate scientific and epidemiological principles. Determine, based on the analysis, what factors are likely to cause the problem or risk. Determine and communicate an appropriate response. Evaluate the effectiveness of any action taken. Case finding is the only public health intervention on the Public Health Intervention Model that is done strictly at the individual/family level. The basic steps in case finding are: 25

1. Identify those individuals and families at particular risk through information from surveillance, disease and health event investigation, and/or outreach. In the case of lead poisoning, the public health nurse investigating the case would do case finding by asking about other children who live in the household or frequently visit as well as if the child spends a great deal of time at other dwellings, such as a day care or relatives home. 2. Connect with formal and informal networks to find those identified as at-risk. In the case of lead poisoning, it is important to maintain strong ties with your community partners as well as develop a trusting relationship with the individual and family. 3. Providing the family with information about how services can be obtained is also important. This is accomplished through the related public health interventions of health teaching and counseling to increase the knowledge of the individual and family about the potential for harm. If the individual and family are facing barriers to treatment, the PHN may need to use the public health intervention of advocacy, consultation and referral and follow-up to help the individual and family resolve the barriers. 4. If the level of risk suggests endangerment to the individual, family, or community, the PHN should provide direct access to necessary services. 5. Fulfill all reporting requirements mandated by state laws and regulations, such as those regarding lead poisoning. Some of the other public health interventions that the public health nurse may utilize include: 1. Referral and Follow-up: assisting individuals, families, groups, organizations, and communities to utilize necessary resources to prevent or resolve problems or concerns. The public health nurse may possibly refer this child to a medical provider for follow-up testing. 2. Case Management optimizes self-care capabilities of individual and families and the capacity of systems and communities to coordinate and provide services. Case management is a gold standard of care in lead poisoned children. 3. Delegated functions are direct care tasks a registered professional nurse carries out under the authority of a health care practitioner, as allowed by law. If the child did not have a medical provider or insurance, the public health nurse may draw the venous blood level under the authority of the agency medical director. 4. Health teaching is communicating facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices and skills of individuals, families, 26

systems, and/or communities. Health teaching is probably one of the most used public health interventions. It is very important in the family of a lead poisoned child, as the family will need to learn how to prevent poisoning from occurring, as well as how to abate the hazard. We are going to wrap up this module with some other environmental health hazards a public health nurse may be asked to assist with. The first one is air quality. The quality of the air in a home can affect the family s comfort and health. The temperature and humidity should be controlled. Air should be clean and free of harmful chemicals and smoke. Poor air quality can cause a stuffy nose, sore throat, burning eyes, headache, and sleepiness. People who have asthma, allergies or lung disease are affected more than others. Health officials worldwide have only recently begun to understand the health problems seen in people who regularly cook or work around wood fires. Wood smoke contains a mixture of at least 100 different compounds in the form of gases and fine sooty particulate matter. At the relatively low temperatures at which outdoor wood burners are designed to burn wood, the stoves can produce thick smoke and creosote. This smoke can contain unhealthy levels of toxic air pollutants and known carcinogens. People with heart disease, asthma, emphysema, or other respiratory diseases are especially sensitive. In particular, wood smoke can be harmful to the 27

elderly, babies, children, and pregnant women. The public health nurse, as an advocate, may work with local policymakers to propose regulations or bans for outdoor wood burners. Molds grow abundantly in outdoor plant and soil materials. Molds produce spores that are normally found in both indoor and outdoor dust. Mold growth is familiar to most people when it is seen as a fuzzy patch or stain spreading across food or damp surfaces. It is known that many molds produce chemicals that can be toxic if eaten. Little if any of these chemicals are commonly found in indoor air and are not suspected to be a health hazard to the general public. Mold exposure from breathing indoor or outdoor air can be irritating and can aggravate allergies and asthma. Health effects of mold can be a concern where exposures are very high, such as in sawmills, grain elevators, and agricultural settings. It is not practical to expect a building to be completely free of mold, nor is it necessary. However, mold growth on indoor surfaces is a sign of moisture presence, the cause of which should be identified and corrected. A public health nurse may note mold in a home during a home safety assessment and provide health teaching to the family about how to rid the home of mold and prevent it from recurring. Mold is a common concern after flooding and the Bureau of Environmental Health has many good resources related to flooding. 28

Radon is a naturally occurring, odorless radioactive gas that causes lung cancer. Between five and ten percent of the homes in Wisconsin have radon levels above the US EPA guideline of 4 picocuries per liter for the year average on the main floor. Every region of Wisconsin has some homes with elevated radon levels. The only way to know the radon level in a house is to measure it. You can get Radon test kits in hardware stores. Local health departments often provide radon test kits to home owners free or at a low cost through grants provided the Radon section of the Bureau of Environmental and Occupational Health. Radon can be controlled in any house. State, local, and tribal health agencies play an extremely important role in all-hazards emergency preparedness and response. The Agency for Toxic Substances and Disease Registry began this initiative to support environmental health knowledge, skills, and awareness among nurses who serve individuals and communities. Nurses are important to environmental health because they play key roles in protecting the health of all people; are in direct contact with individuals, families, and communities from many cultural and socioeconomic backgrounds; and have the credibility and access that enables them to provide scientifically sound information about environmental issues and toxic exposures. The initiative promotes and supports nurses' contributions to promoting environmental health for individuals and communities. The initiative is a collaborative effort to increase and sustain environmental health knowledge and skills in nurses and other health professionals. 29

A chemical emergency occurs when a hazardous chemical has been released and the release has the potential for harming people's health. Chemical releases can be unintentional, as in the case of an industrial accident, or intentional, as in the case of a terrorist attack. Some chemicals that are hazardous have been developed by military organizations for use in warfare. Examples are nerve agents such as sarin, mustards such as sulfur mustards and nitrogen mustards, and choking agents such as phosgene. Many hazardous chemicals are used in industry, for example, chlorine, ammonia, and benzene and others are found in nature such as poisonous plants. The Bureau of Environmental and Occupational Health has fact sheets available on most of the chemicals encountered by public health professionals, check out the Bureau of Environmental and Occupational Health for a full listing of what is available. The Hazardous Substances Emergency Events Surveillance (HSEES) system collects and analyzes information about sudden uncontrolled or illegal releases of hazardous substances and threatened releases that result in public health action, such as evacuation. The HSEES system aims to reduce injury and death among first responders, employees, and the general public that result from releases of hazardous substances. A substance is considered hazardous if it might reasonably be expected to cause adverse health effects to humans. Fifteen state health departments participate in HSEES through cooperative agreements with ATSDR, including Wisconsin. Participating states provide information about the release, such as time and place, circumstances, substances involved, persons affected, and public health action taken. Some of the information obtained from the system includes: Approximately 9,000 hazardous substances releases occur annually in the 15 states reporting Facilities account for 70% 75% of the releases and transportation-related releases account for 25% 30%. Most releases occur on weekdays between 6 AM and 6 PM and the number tends to increase in spring and summer. Releases of hazardous substances most often injure employees, followed by the general public and less frequently first responders and school children. Respiratory irritation and eye irritation are the most commonly reported symptom or injury. 30

Methamphetamine, an illegal substance also known as meth, speed, crank, crystal, and ice, is a potent synthetic drug that is a stimulant of the central nervous system. Meth is an increasingly popular drug that can be injected, snorted, taken orally, or smoked. Meth is often made in makeshift laboratories, such as rented apartments, storage units, or hotel rooms. During the production of meth, a property can become contaminated with hazardous chemicals, and there is a strong risk of fire or explosion. Public health is an important partner in meth lab investigations because human health hazards can remain after the seizure of a clandestine meth lab. Local health departments are responsible for dealing with human health hazards. When a meth lab is discovered, the local law enforcement agency and/or the Division of Criminal Investigations, is responsible for making arrests and seizing the lab. Evidence is removed from the site, and chemical hazard consultants are brought in by law enforcement to remove containers of hazardous chemicals related to the operation of the meth lab. Officials may also screen indoor air. Once containers of chemicals and equipment related to the meth lab have been removed, the health department evaluates the property for long-term exposure risks from residual chemicals. Additionally, the Department of Natural Resources may assess environmental impacts from outdoor chemical spills or improper waste disposal. When visiting a site, especially the first time, a member of local law enforcement should accompany the public health investigation staff to describe the situation, and can help in the event of unexpected encounters with occupants or visitors. The Bureau of Environmental and Occupational Health website has many excellent resources for public health departments who face a meth lab challenge. 31

One last note--never enter an area you suspect may have a chemical release--leave it to the professionals who are trained and equipped to handle it! The HAZMAT teams are equipped with the Personal Protective Equipment and knowledge to safely investigate the spill or release. If you suspect you are in the vicinity of a release or spill: Stay calm. Evacuate the area if it is safe to do so. Do not touch or remove anything. Call 911 and be ready to provide: Your name, agency and telephone number The type, date and time of incident The facility name and/or location of incident Any other pertinent information Follow first responders instructions about what to do and where to go. If you suspect that you have been contaminated with a chemical or are experiencing symptoms that cause you to believe you may have been exposed to a chemical you may obtain further advice from the State s Poison Control Center at 1-800-222-1222. Foodborne and waterborne disease outbreaks are of urgent public health importance and immediate reporting of these diseases or outbreaks by physicians, laboratory directors and 32

other public private health care providers to local health departments is mandated by Wisconsin law. Most gastrointestinal illnesses are category 2 on the 4151, but a suspected outbreak is a category 1 and should be reported immediately. The public depends on health departments and food regulators for protection from foodborne illness. Such protection relies on rapid detection of outbreaks, determination of the cause of the outbreak, and incorporation of control measures to protect the public. The careful and diligent investigation of foodborne and waterborne outbreaks is essential for disease control and prevention. Investigation of food and waterborne disease outbreaks are rarely, if ever, accomplished by a single individual. A proper investigation generally requires the efforts of a team of individuals with different areas of expertise. The Communicable Disease Epidemiology Section provides the Foodborne and Waterborne Disease Outbreak Investigation Manual to guide a health department through the steps of a foodborne or waterborne outbreak. Your agency should have a copy of the manual and it is also located on the Health Alert Network. The Health Alert Network, or HAN, was introduced to you in the communicable disease module. Foodborne and waterborne outbreaks are investigated by public health nurses and sanitarians in consultation with the health officer and the medical director. Some of the steps a public health nurse may do include: 1. Conduct the initial investigation of a suspected outbreak. The investigation should be directed by the LHD in whose jurisdiction the outbreak originated. 2. Immediately notify the CDES and/or the Bureau of Public Health Practice and Emergency Medical Services Regional Office of any outbreak as early in the investigation as possible. 3. Request assistance of the Communicable Disease Epidemiology Section and/or the Regional Office, if needed, to control the spread of the outbreak. 4. Obtain clinical and environmental specimens, conduct interviews, compile line lists, record onset times and other important epidemiologic data. 5. Provide education to food workers regarding proper food handling and personal hygiene. 6. Complete a foodborne or waterborne outbreak report and mail a copy to CDES. This may be done in conjunction with the CDES. 7. Maintain an ongoing foodborne disease complaint file or log. 33

Some of the steps a public health nurse may help the registered sanitarian do are: 1. Coordinate environmental investigation with epidemiologic investigations. 2. Conduct or direct a complete sanitation investigation of the facility or site of a suspected outbreak. 3. Collect food, water, and other specimens as needed. Safe, clean drinking water is what we expect when we turn on our faucets. The Wisconsin Bureau of Drinking Water and Groundwater manages activities that affect the safety, quality and availability of drinking water by preventing contamination of drinking water and groundwater to protect public health. About two-thirds of Wisconsin's population drinks water drawn from over 750,000 private wells. Wells are safe, dependable sources of water if sited wisely and built correctly. Unlike public water systems, protection and maintenance of a private well is largely the responsibility of homeowners and need periodic testing. Access the Wisconsin Department of Natural Resources Drinking and Groundwater Section for many excellent resources for more information about drinking water and its relation to public health. 34

Mercury is a heavy, silvery-white metal element. It can exist as a liquid at room temperature or as a solid crystal salt. The liquid metal form gives off invisible, odorless, toxic vapors. Mercury can also be found in organic (with carbon) compounds. Commonly, metallic mercury can be found in thermometers, barometers, electrical switches, thermostats, sphygmomanometers, and in dental fillings. When mercury is released from industries into the air, it can travel long distances and be deposited on soil and in lakes. In lakes, small organisms change the mercury to a form of organic mercury (methylmercury) that builds up in the bodies of fish. Some lakes in Wisconsin have health advisories that recommend against eating too much of certain types of fish containing high levels of methylmercury. Wisconsin is known for its recreational waters and water parks. Public health officials encourage healthy and safe practices to reduce the spread of infectious diseases, drowning and injury while enjoying summer water recreation. Swallowing, breathing, or having contact with contaminated water from swimming pools, spas, lakes, and rivers can cause illness. Recreational water illnesses can cause a wide variety of symptoms including skin, ear, respiratory, eye, and wound infections. The most commonly reported illness is diarrhea which can be caused by germs such as cryptosporidium, giardia, shigella and E. coli. Children, pregnant women, and persons with compromised immune systems are at greatest risk from infection. Local public health departments offer varying amounts of service in this area and may 35

include safe recreational water use education, local public health laboratory testing services, pool inspection service or beach water monitoring. Some of the public health interventions the public health nurse uses when assisting with food and water issues include: 1. Health teaching is communicating facts, ideas, and skills that change knowledge, attitudes, values, beliefs, behaviors, and practices and skills of individuals, families, systems, and/or communities. Teaching a family how much fish is recommended in their diet is an example of health teaching. 2. Disease & Health Event Investigation. The PHN responded to a request to help investigate a possible hazard that may have an impact on human health. The PHN defined the problem, established clear criteria for what constituted an event, considered existing data, generated and analyzed additional data, determined the cause and risk of the problem and communicated an appropriate response. The public health nurse uses disease and health investigation when she or he interviews a case who became sick after eating in a restaurant. 3. Case finding occurs as a result of screening, disease and health event investigation and surveillance, locating individuals and connecting them to services. The public health nurse does case finding when investigating a foodborne outbreak and asks the case if they know of anyone else who is ill. 4. Consultation: The PHN works with the sanitarian to investigate the foodborne outbreak. 36

An environmental issue that impacts nurses as well as the public is latex allergies. Protecting yourself and your clients from latex allergies includes: Use nonlatex gloves for activities that are not likely to involve contact with infectious materials If you choose latex gloves, use powder-free gloves with reduced protein content. When wearing latex gloves, do not use oil-based hand creams or lotions (which can cause glove deterioration). After removing latex gloves, wash hands with a mild soap and dry thoroughly. Learn to recognize the symptoms of latex allergy: skin rash; hives; flushing; itching; nasal, eye, or sinus symptoms; asthma; and (rarely) shock. Always remember-safety first! Enforcing public health laws and being part of environmental health assessment teams can infrequently put the public health nurse at risk for injury from irate residents. Public health nurses should always partner with local law enforcement to accompany them on any visits in which violence is a potential concern. 37

This program was developed through a partnership between the Wisconsin Department of Health Services and the Linking Education and Practice for Excellence in Public Health Nursing (LEAP) Project. This module would not have been possible without the input of the many public health nurses in academia and practice across the state of Wisconsin who contributed to this program. We would like to give special thanks to those who provided content review of this module. Expert consultation for this module was provided by Reghan Walsh, Lead and Asbestos Program, Bureau of Environmental and Occupational Health, Division of Public Health. References: Agency for Toxic Substance and Disease Registry. (2008). Fact sheet: Hazardous substances emergency events surveillance system. Retrieved April 4, 2008 from: http://www.bt.cdc.gov/surveillance/hsees.asp American Public Health Association, Public Health Nursing Section. (2005). Environmental health principles & recommendations for public health nursing. Retrieved March 28, 2008, from http://www.apha.org/membergroups/sections/aphasections/phn/benefits/ University of Minnesota Center for Public Health Education. (n.d.). Emergency preparedness and response for environmental health professionals. Minneapolis, MN: Author. Minnesota Department of Health. (2001). Public health interventions. St. Paul, MN: Author. Valanis, B. (1999). Epidemiology in health care. Stamford, CT: Appleton & Lange. 38