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CHILDREN AND CHEMICALS TRAINING FOR THE HEALTH SECTOR [Date …Place …Event…Sponsor…Organizer] Children's Health and the Environment WHO Training Package.

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Presentation on theme: "CHILDREN AND CHEMICALS TRAINING FOR THE HEALTH SECTOR [Date …Place …Event…Sponsor…Organizer] Children's Health and the Environment WHO Training Package."— Presentation transcript:

1 CHILDREN AND CHEMICALS TRAINING FOR THE HEALTH SECTOR [Date …Place …Event…Sponsor…Organizer] Children's Health and the Environment WHO Training Package for the Health Sector World Health Organization CHILDREN AND CHEMICALS October

2 Children and chemicals 2   Learn about chemical hazards – what they are and the risks they may pose to children   Identify the scenarios – how, where and when are children exposed?   Recognize signs, symptoms and diseases due to acute and chronic toxic exposures in children   Know how to assess, prevent and treat children's toxic exposures LEARNING OBJECTIVES

3 Children and chemicals 3 CHEMICALS AMONG OTHER GLOBAL ENVIRONMENTAL HEALTH ISSUES   Chemical hazards   Air pollution - indoor and outdoor   Household water insecurity   Poor hygiene and sanitation   Disease vectors   Injuries and accidents   Emerging issues - Climate change - POPs - Ozone layer WHO

4 Children and chemicals 4 CHEMICALS ARE USED IN EVERYDAY LIFE Benefits   Promote hygiene   Protect crops   Control vectors Risks   Adverse health effects   Unwanted pollutants in the environment   Persistence WHO

5 Children and chemicals Acute and chronic, high and low- level exposures to chemicals in the environments of children may cause functional and organic damage, during periods of special vulnerability “Children are not little adults”… Informed health care providers play a key role in preventing and managing diseases CHILDREN AND TOXICANTS CHILDREN AND TOXICANTS WHO

6 Children and chemicals 6 EXPOSURE TO CHEMICALS AT HOME, SCHOOL, PLAYGROUND, FIELDS & STREETS Different exposures expected from rural and urban settings by:   Household products, building materials, house dust, food contaminants, and toys   Pharmaceuticals, cosmetics, and hygiene products   Second-hand smoke   Workplace (of the parents, or the child, "take home" exposures)   Persistent Organic Pollutants (POPs) in the environment   Chemicals of natural origin:   e.g: fluoride in water, aflatoxins, cyanide, pyrrolizidine alkaloids   Mixed chemicals

7 Children and chemicals 7 CHILDREN'S CHEMICAL EXPOSURES ARE MAGNIFIED IN DEVELOPING AND TRANSITIONAL COUNTRIES   Unsafe use of chemicals   Increasing pollution and uncontrolled use of chemicals   Chemical dumping   Additional factors: malnutrition, infectious diseases, poverty   Child work and scavengers   Lack of awareness of risks   Lack of interest   Despair at the magnitude of the problem

8 Children and chemicals Developmental Physiology Increased energy requirements Different metabolism Windows of susceptibility Longer life and latency Politically Powerless Unique Exposures Unique pathways Behaviors Poor understanding Microenvironments VULNERABILITY OF CHILDREN 8

9 Children and chemicals 9 EFFECTS Organs Systems Functions Development RISKS Physical Chemicals Biological MEDIA Water - Air - Food - Objects SETTINGS URBAN & RURAL Home School Playground Field Street Workplace CIRCUMSTANCES Eating, Drinking, Playing, Learning, Working, Scavenging CHILDREN'S COMPLEX ENVIRONMENT Ceppi, Corra VULNERABILITY Dynamic, developmental physiology and "windows of vulnerability"

10 Children and chemicals TOXICOKINETICSAND TOXICODYNAMICS TOXICOKINETICS AND TOXICODYNAMICS  Toxicokinetics - all the processes and pathways that a substance goes through in the body  Toxicodynamics the interaction between a substance and the body, resulting in toxic effects Simply stated, toxicokinetics refers to what the body does to the toxin, while toxicodynamics refers to what the toxin does to the body

11 Children and chemicals 11 How are xenobiotics handled by an immature, anabolic body?   Absorption   Energy, water, oxygen consumption   Biotransformation   Activation/detoxification   Distribution   Fat   Blood-brain barrier   Elimination   Critical windows of development   Development of organs and systems WHO TOXICOKINETICS TOXICOKINETICS

12 Children and chemicals 12 Moore, Elsevier Inc, 1973 DYNAMIC DEVELOPMENTAL PHYSIOLOGY WINDOWS OF DEVELOPMENT

13 Children and chemicals TRANS-GENERATIONALTOXICANTS TRANS-GENERATIONAL TOXICANTS   Exposure occurs during youth   Prolonged half lives (up to 10 years) As women enter childbearing years the toxicant moves transplacentally and has adverse effects on development Examples: Polychlorinated biphenyls (PCBs) - Yusho and Yu-cheng Methyl mercury- Iraq   Prevention is key

14 Children and chemicals Maternal exposure to:   Mercury, ethylene oxide, rubber chemicals, solvents, are linked to spontaneous abortion Pre-conception   PCBs and lead maternal body burdens are linked to abortion, stillbirth and learning disabilities   Folate deficiency leads to neural tube defects In utero exposures: Thalidomide phocomelia X-rays leukaemia Heat neural tube defects Alcohol FAS (fetal alcohol syndrome) LeadNeurodevelopmental effects Methyl mercuryNeurodevelopmental effects DEVELOPMENTAL PHYSIOLOGY: PARENTS AND THEIR OFFSPRING 14

15 Children and chemicals 15 TOXICODYNAMICS TOXICODYNAMICS HOW DO TOXIC EFFECTS OCCUR?   During critical windows of exposure   On critical organs/systems   Central nervous system (CNS)   Immune system   Endocrine system   Other organs   A child is building the body for a “lifetime”. WHO

16 Children and chemicals 16 ROUTES OF EXPOSURE   Unique exposure pathways   Transplacental   Breastfeeding   Exploratory behaviors leading to exposure   Hand-to-mouth, object-to-mouth   Non-nutritive ingestion   Stature and living zones, microenvironments   Surface area to volume ratio   Children do not understand danger   Pre-ambulatory   Adolescents have “high risk” behaviors

17 Children and chemicals 17   Water Drinking Recreational   Air Indoor Outdoor   Food   Cosmetic and hygiene products   Objects and toys MEDIA OF EXPOSURE MEDIA OF EXPOSURE WHO PAHO

18 Children and chemicals  Poverty limits adaptive responses to both climate change and chemical exposures.  Malnutrition may compound and worsen effects from toxic exposure.  Geography is a major determinate of which health threats from climate change are most likely, and places entire populations at increased risk.  Occupations that involve the use of chemicals, such as agricultural work, may be increasingly risky because of increased chemical use, change in chemicals used and rapid development of new chemicals.  Public health infrastructure, chemical safety laws, regulations, surveillance and enforcement, are critical to minimizing injury and illness related to climate change and chemical exposures. CLIMATE CHANGE AND CHEMICALS

19 Children and chemicals TOXIC SUBSTANCES IN TOYS AND ARTICLES   Toys: lead, cadmium and phthalates   Jewellery: lead, cadmium   Electronic products: lead, mercury, cadmium, and brominated flame retardants   Batteries: lead and other heavy metals   Textiles : perfluorinated compounds in waterproof garments, nonylphenol ethoxylates as surfactants   Furniture : fungicides 19 U.S. Environmental Protection Agency

20 Children and chemicals 20   Anthropogenic "man-made"   Industry   Traffic   Additives and contaminants   Contaminated areas   Natural   Arsenic   Fluoride   Plants   Aflatoxins   Blue-green algae SOURCES OF EXPOSURE IN THE ENVIRONMENT SOURCES OF EXPOSURE IN THE ENVIRONMENT WHO Ceppi, Corra

21 Children and chemicals 21   Unintentional ("accidental")   Intentional   Iatrogenic   Occupational   ‘Take-home’   ENVIRONMENTAL CIRCUMSTANCES OF EXPOSURE CIRCUMSTANCES OF EXPOSURE WHO

22 Children and chemicals 22  Prenatal  Newborns  Toddlers  School children  Adolescents SCENARIOS OF EXPOSURE : SCENARIOS OF EXPOSURE : AGE AND GENDER GROUPS WHO Corra WHO

23 Children and chemicals 23   Acute : Exposure over a short period of time (e.g. 24 hours)   Single: a single or unique and continuous exposure   Repeated: multiple exposures; potential accumulation   Chronic or long-term Continuous or repeated exposure (e.g. more than 24 hours, for weeks or months)   "Acute on chronic" An acute exposure against a background of chronic exposure to the same agent   "Hit and run" Acute exposure leading to delayed effects once the toxicant is gone TYPE OF EXPOSURE TYPE OF EXPOSURE

24 Children and chemicals 24   High-dose exposure poisoning   Low-dose exposure subtle effects (more recently recognized) Concern raised by persistent organic pollutants (POPs) and potential developmental neurobehavioral and endocrine effects HIGH AND LOW DOSE EXPOSURES HIGH AND LOW DOSE EXPOSURES Subtle effects do not equal minor effects!

25 Children and chemicals 25 CLINICAL AND SUBCLINICAL EFFECTS CLINICAL AND SUBCLINICAL EFFECTS Clinical features observed depend upon:   Agent (chemical, physical, biological)   Dose   Timing and length of exposure May be:   Asymptomatic   Acute and evident: toxic syndromes   Chronic and subtle: undefined symptoms   Detected only by laboratory studies WHO

26 Children and chemicals 26 According to Poisons Centres :   Up to 50% to 70% of the calls are about children exposed to chemicals or actually poisoned   Number of poisoning cases is underestimated   Cases of exposure are mostly acute and accidental   The majority are between 1 & 4 years old   Boys are more affected   The outcome is usually favourable   Mortality is usually low ACUTE POISONINGS U.S. Environmental Protection Agency

27 Children and chemicals 27   Pharmaceuticals: sedatives, analgesics, contraceptives syrups, contaminants   Household products: bleaches, cleaners, detergents, solvents, kerosene (paraffin)   Cosmetics: perfumes, shampoo, nail products   Plants and mushrooms: berries, seeds, leaves   Drugs of abuse: alcohol, illicit drugs of abuse, tobacco   Pesticides: insecticides, rodenticides, herbicides   Bites and stings: "envenoming" by snakes, scorpions, spiders, bees CHEMICALS – ACUTE POISONINGS CHEMICALS – ACUTE POISONINGS

28 Children and chemicals 28 ACUTE POISONINGS ACUTE POISONINGS Pharmaceuticals: one teaspoon or pill can be dangerous! Benzodiazepines Tricyclic antidepressants Codeine Diphenoxylate (Lomotil) Theophylline Antidiabetic sulfonylureas Digitalis Antihypertensives Methyl salicylate Iron Quinidine Chloroquine Lindane Camphor WHO

29 Children and chemicals 29 PESTICIDES   Spraying of pesticides at home and in schools increases exposure to children due to:   Higher concentrations near the floor   Persistence in some surfaces, such as carpets and soft toys   Overuse and misuse of pesticides   Children activities contribute to inhalation of pesticides   Crawling   Playing close to the floor   Hand-to-mouth and object-to-mouth activities WHO

30 Children and chemicals 30 SOLVENTS & VOLATILE ORGANIC COMPOUNDS Aromatic hydrocarbons, alcohols, aldehydes, ketones. Sources:   Solvents, fabric softeners, deodorizers and cleaning products   Paints, glues, resins, waxes and polishing materials   Spray propellants, dry cleaning fluids   Pens and markers   Binders and plasticizers   Cosmetics: hairspray, perfumes U.S. Environmental Protection Agency

31 Children and chemicals 31   Pesticides   Metals   Lead, Arsenic, Mercury   Other heavy metals   Persistent organic pollutants (POPs) CHEMICALS: CHRONIC EXPOSURE CHEMICALS: CHRONIC EXPOSURE

32 Children and chemicals PESTICIDES: CHRONIC EXPOSURE 32   Child-care centres   Schools   Children spend hours   Close to the ground   Touching and tasting   Pesticides applied remain in carpets and fabrics. Levels of chlorpyrifos vapours in the child’s breathing zone (25 cm) are 94 microg/m 3 but in the adult’s breathing zone (100 cm) are 64 microg/m 3 Exposure of neonatal rats to chlorpyrifos produced brain cell damage and loss, with resultant abnormalities of synaptic development. WHO

33 Children and chemicals LEAD TOXICITY: CHRONIC EXPOSURE 33 Agency for Toxic Substances and Disease Registry

34 Children and chemicals 34   Confirm exposure to toxicants   Determine magnitude / severity   Assess and measure effects   Monitor the efficacy of treatment   Follow up the clinical evolution ROLE OF THE LABORATORY ROLE OF THE LABORATORY WHO

35 Children and chemicals 35   Acute (e.g. Organophosphorus Pesticide):   Resuscitation (intubation, ventilation, life-saving measures)   Decontamination   Symptomatic treatment   Specific treatment: use of antidotes or antagonists   Chronic / low-level exposure (e.g. lead) requires:   Removing the child from the source of exposure   Symptomatic treatment   Specific treatment: use of antidotes, if appropriate   Follow-up treatment (long term)   Remedial measures to environment Important: Consult the Poison Centre ! TREATMENT OF TOXIC EXPOSURES TREATMENT OF TOXIC EXPOSURES

36 Children and chemicals 36 PREVENTION OF EXPOSURE IS THE SINGLE MOST EFFECTIVE MEANS OF PROTECTING CHILDREN AGAINST TOXICANTS   Identifying the problem   Defining its determinants and characteristics   Informing the community – and the children!   Educating colleagues and other professionals   Raising the awareness of policy-makers   Promoting the implementation of the appropriate measures   Helping to evaluate the efficacy of preventive measures WHO Health care providers play a key role in:

37 Children and chemicals CASESTUDY: THAI SCHOOLCHILDREN AND PESTICIDES CASE STUDY: THAI SCHOOLCHILDREN AND PESTICIDES  Schools aim to identify toxic pesticides available in the farming communities and the hazardous uses  Children also assess the acute health effects suffered by their parents by conducting a health history and examination before and after spraying.  Goal is to raise awareness among children and their parents about the hazards of pesticides and to eliminate exposure and the resulting adverse health effects

38 Children and chemicals CASESTUDY: THAI SCHOOLCHILDREN AND PESTICIDES CASE STUDY: THAI SCHOOLCHILDREN AND PESTICIDES Results:  Household pesticide storage and disposal practices improved.  Initially, students identified that pesticides were stored in areas where children played  After 4 months, the proportion of houses defined as “child unsafe” had decreased from 64% to 45%.  Pesticide storage and disposal that were potentially contaminating food, water and livestock improved by 31%, 22%, and 20%respectively.  Homes recycling pesticide containers diminished from 16% to 5%.  Students reported that their parents took greater care to protect themselves during spraying. All wore rubber gloves and boots and none smoked during the spray operation.  Of the 18 signs and symptoms of health effects initially reported by parents, all but two decreased in frequency.

39 Children and chemicals  Ensure safe storage, packaging, clear labelling, of cleaners, fuels, solvents, pesticides and other chemicals used at home and in school.  Promote the use of child-resistant packages for pharmaceuticals and for chemical products.  Inform parents, teachers and child-minders about the potential chemical hazards in the places where children spend their time.  Train healthcare providers on the recognition, prevention and management of toxic exposures, and on the use of the paediatric environmental history to investigate specific risks to which children are exposed.  Incorporate the teaching of chemical safety and health into school curricula. PROTECT CHILDREN FROM ALL CHEMICAL HAZARDS

40 Children and chemicals  Create and enforce legislation to promote the safe use and disposal of chemicals.  Promote policies to reduce and remedy environmental pollution.  Avoid the construction of homes, schools and playgrounds near polluted areas and hazardous installations.  Poisons, medicines, bleach, acid, and liquid fuels such as kerosene should never be stored in drinking bottles. All such liquids and poisons should be kept in clearly marked closed containers out of children's sight and reach PROTECT CHILDREN FROM ALL CHEMICAL HAZARDS

41 Children and chemicals  Publications for all audiences: health professionals, scientists, policy-makers, communities    Summary of Principles for Evaluating Health Risks in Children Associated with Exposure to Chemicals  Training package on child health and environment  Birth cohort studies initiative  National profiles on child health and environment  Pediatric environmental health history  UNEP/WHO Toxicology in the classroom toolkit for schoolchildren  PROTECT CHILDREN FROM ALL CHEMICAL HAZARDS WHO TOOLS AVAILABLE

42 Children and chemicals 42   1992 Agenda 21, Ch. 25 (United Nations Conference on Environment and Development)   1997 Declaration of the Environment Leaders of the Eight on Children’s Environmental Health   1999 Declaration of the Third European Ministerial Conference on Environment and Health   2002 Bangkok Statement (WHO International Conference)   2003 Recommendations of the Intergovernmental Forum on Chemical Safety (IFCS) on Children and Chemicals   2004 Budapest Ministerial Conference on Environment and Health (CEHAPE) SOME INTERNATIONAL AGREEMENTS ON THE PROTECTION OF CHILDREN'S HEALTH FROM THE EFFECTS OF CHEMICALS

43 Children and chemicals 43   2004 Health and Environmental Ministerial Meeting of the Americas (HEMA)   2005 Buenos Aires Declaration (2 nd WHO, International Conference) –   2009 Declaration of the Environment Leaders of the Eight on Children’s Environmental Health   2009 Busan Pledge for Action (3 rd WHO International Conference) –   Health and Environment Ministerial meetings in WHO regions (Africa, Western Pacific, …) – SOME INTERNATIONAL AGREEMENTS ON THE PROTECTION OF CHILDREN'S HEALTH FROM THE EFFECTS OF CHEMICALS …CONTINUED

44 Children and chemicals 44   Learn about chemical hazards in children – what they are and what are the risks they may pose?   Identify the scenarios – how, where and when are children exposed?   Recognize signs, symptoms and diseases that may be related to acute and chronic toxic exposures in children   Know how to assess, prevent and manage children's toxic exposures WERE THE LEARNING OBJECTIVES REACHED? WERE THE LEARNING OBJECTIVES REACHED?

45 Children and chemicals 45 POINTS FOR DISCUSSION

46 Children and chemicals 46 First draft prepared by Jenny Pronczuk MD (WHO) With the advice of the Working Group Members on the Training Package for the Health Sector: Cristina Alonzo MD (Uruguay); Yona Amitai MD MPH (Israel); Stephan Boese-O’Reilly MD MPH (Germany); Stephania Borgo MD (ISDE, Italy); Irena Buka MD (Canada); Ernesto Burgio (ISDE, Italy); Lilian Corra MD (Argentina); Ligia Fruchtengarten MD (Brazil); Amalia Laborde MD (Uruguay); Jenny Pronczuk MD (WHO) Christian Schweizer TO (WHO/EURO); Kathy Shea MD (USA). Reviewers: Ligia Fruchtengarten MD (Brazil); Josef G. Thundiyil MD, MPH (USA), Renee Modica MD, MSEd (USA), Carolyn Vickers MSc (WHO), Dr Huw Brunt (UK), Prof Gary Coleman (UK), Dr Raquel Duarte-Davidson (UK), Dr Elaine Lynch Farmery (UK), Alison M Good BSc Dip Med Tox MSc (UK), Dr Mark Griffiths (UK), Dr John Thompson (UK), Dr Laura Yates (UK) WHO Project coordination: Ruth A. Etzel, MD PhD Marie-Noël Bruné, MSc Latest update: October 2011 (H. Graczyk, L. Tempesta) ACKNOWLEDGEMENTS WHO is grateful to the US EPA Office of Children’s Health Protection for the financial support that made this project possible and for the data, graphics and text used in preparing these materials. Further support was kindly provided by the UK Department of Health.

47 Children and chemicals 47 DISCLAIMER   The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.   The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.   The opinions and conclusions expressed do not necessarily represent the official position of the World Health Organization.   This publication is being distributed without warranty of any kind, either express or implied. In no event shall the World Health Organization be liable for damages, including any general, special, incidental, or consequential damages, arising out of the use of this publication   The contents of this training module are based upon references available in the published literature as of its last update. Users are encouraged to search standard medical databases for updates in the science for issues of particular interest or sensitivity in their regions and areas of specific concern.   If users of this training module should find it necessary to make any modifications (abridgement, addition or deletion) to the presentation, the adaptor shall be responsible for all modifications made. The World Health Organization disclaims all responsibility for adaptations made by others. All modifications shall be clearly distinguished from the original WHO material.

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