Radon is a naturally occurring radioactive gas emitted from the natural decay of uranium and found in nearly all soils; it may seep into buildings from the surrounding soil. The EPA ranks indoor radon among the most serious environmental health problems facing us today. It is the second leading cause of lung cancer in the United States (smoking is the first), causing an estimated 14,000 lung cancer deaths per year. The combination of exposure to radon and smoking significantly increases the risk of cancer. Approximately 1 out of every 15 homes in the United States is estimated to have elevated radon levels. You cannot see, taste, or smell radon.
Radon decays into radioactive particles that can be trapped in the lungs where they damage lung tissue and may lead to lung cancer. The risk of developing lung cancer from radon exposure depends on: (1) the amount of radon in the home (dose); (2) the amount of time spent in the home (duration); and (3) whether the individual is a smoker or has ever smoked (host factor).
Figure 2 shows how radon may enter buildings.
Figure 2. Radon may enter buildings through:
If radon is present in well water, radon gas may be released into the air when the water is used for showering and other household uses. Research suggests that drinking water with high radon levels may also pose risks; however, this risk is much lower than risks associated with breathing radon.
Testing is the only way to know if a home has an elevated radon level. The EPA and the Surgeon General recommend testing all homes below the third floor for radon. There are many kinds of low-cost "do-it-yourself" radon test kits that homeowners can purchase in hardware stores and other retail outlets. State radon offices also provide a list of trained contractors who conduct the tests. Nurses should test their homes and encourage neighbors and patients to test theirs.
Testing for Radon
Short-term testing. The quickest way to test for radon is with short-term tests. Short-term tests remain in your home for 2-90 days, depending on the device. Charcoal canisters, alpha track, electret ion chamber, continuous monitors, and charcoal liquid scintillation detectors are most commonly used for short-term testing. Because radon levels tend to vary from day to day and season to season, a short-term test is less likely than a long-term test to tell you your year-round average radon level. If you need results quickly, however, a short-term test followed by a second short-term test may be used to decide whether to fix your home.
Long-term testing. Long-term tests remain in your home for more than 90 days. Alpha track and electret detectors are commonly used for this type of testing. A long-term test will give you a reading that is more likely to tell you your home's year-round average radon level compared with a short-term test.
How to use a radon test kit. Follow the instructions that come with your test kit. If you are doing a short-term test, close your windows and outside doors and keep them closed as much as possible during the test. (If you are doing a short-term test lasting just 2 or 3 days, be sure to close your windows and outside doors at least 12 hours before beginning the test, too. You should not conduct short-term tests lasting just 2 or 3 days during unusually severe storms or periods of unusually high winds.) The test kit should be placed in the lowest lived-in level of the home (for example, the basement if it is frequently used, otherwise the first floor). It should be put in a room that is used regularly (like a living room, playroom, den, or bedroom) but not your kitchen or bathroom. Place the kit at least 20 inches above the floor in a location where it won't be disturbed -- away from drafts, high heat, high humidity, and exterior walls. Leave the kit in place for as long as the package says. Once you have finished the test, reseal the package and send it to the lab specified on the package right away for study. You should receive your test results within a few weeks.
For additional information on how to use a radon test kit see Related Resources for Radon Test Kit.
Carbon Monoxide in the Home
Carbon monoxide (CO) is a colorless, odorless, tasteless, poisonous gas. More than 3800 people die every year in the United States from carbon monoxide poisoning (both accidental and intentional). An additional 10,000 people receive a sublethal exposure which causes them to miss at least 1 day of work or to seek medical attention. Centers for Disease Control and Prevention data from 1996 indicate that there were 525 unintentional deaths in the United States due to CO poisoning.
CO is produced by the incomplete combustion of carbon materials. Any flame or combustion device is likely to emit CO. CO can get trapped inside an area when appliances do not work properly, when a stove or furnace is not working properly due to a clogged chimney or vent, when a car is left running in an enclosed space, or when a charcoal grill is used in a closed area.
CO Poisoning Symptoms
CO combines with hemoglobin to form carboxyhemoglobin, which is incapable of carrying oxygen, resulting in tissue anoxia. The health threat from exposure to CO is especially serious for unborn babies, infants, and people with anemia or a history of heart or respiratory disease. At moderate levels, CO can cause severe headaches, dizziness, confusion, and nausea. If these levels persist for a long time, death can occur. Low levels can cause shortness of breath, mild nausea, and mild headaches, and may have longer-term effects on health. These symptoms are often mistaken for the flu or other illnesses, and may result in delayed or misdiagnosed treatment.
Chronic CO poisoning usually involves lower levels of the gas in the air and lower blood CO (COHb) concentrations. Chronic CO poisoning may not elicit the typical symptoms of (acute) CO poisoning, such as headache, nausea, weakness, and dizziness. Mucous membranes of the body will almost never be cherry pink in chronic poisoning as they are in acute CO poisoning. Chronic CO poisoning is often misdiagnosed as chronic fatigue syndrome, a viral or bacterial pulmonary or gastrointestinal infection, a "run-down" condition, or immune deficiency. Patients occasionally present with polycythemia, with an increased hematocrit. Similar symptoms seen simultaneously in more than 1 person, and which decrease upon removal from an environment, are tip-offs that CO may be involved.
Carbon Monoxide Detectors
CO toxicity levels are usually expressed in airborne concentration levels read in parts per million (ppm) and duration of exposure. CO detectors are designed to protect against acute high levels of carbon monoxide; they are not required or equipped to alarm at lower levels of CO. The Underwriters Laboratories (UL) standard requires detectors to alarm within 90 minutes when exposed to 100 ppm, 35 minutes when exposed to 200 ppm, and 15 minutes when exposed to 400 ppm. (The actual UL standard must be purchased. The Underwriters Laboratories Web site is: http://www.ul.com/) The National Institute for Occupational Safety and Health (NIOSH) time-weighted average standard for CO exposure is 35 ppm, which is well below the lowest UL standard alarm trigger of 100 ppm. Also, both NIOSH and the Occupation Safety and Health Administration have set a standard for CO exposure at 200 ppm as an absolute ceiling that "should not be exceeded at any time."
There are several types of CO detectors on the market. However, they are not as reliable as smoke detectors, and due to the colorless, odorless nature of CO, it is more difficult to identify the cause of a CO alarm. If you shop for a CO detector to warn of acute CO exposures, look for UL certification. Nongovernmental organizations such as Consumers Union (publisher of Consumer Reports), the American Gas Association, and UL can help you make an informed decision. Carefully follow manufacturers' instructions for placement, use, and maintenance of detectors. While a UL-certified CO detector will alarm in the case of high-level CO incidents, it will not alarm at low levels that could pose significant health risks. To prevent and address low-level, chronic CO exposures, maintaining appliances and recognizing symptoms of possible poisoning are essential.
Important Tips for Preventing CO Poisoning
If the CO Detector Alarm Goes Off
Lead is a poison. Childhood lead poisoning remains a major preventable environmental health problem in the United States. Children's still-developing nervous systems are particularly vulnerable to the toxic effects of lead, and their normal play and hand-to-mouth activities expose them to lead-paint hazards and lead-contaminated dust and soil. According to the Centers for Disease Control, estimates from the National Health and Nutrition Examination Survey indicated that Medicaid enrollees accounted for 83% of children aged 1-5 years who had elevated blood lead levels (BLLs). Despite longstanding requirements for blood lead screening in the Medicaid program, an estimated 81% of young children enrolled in Medicaid have not been screened with a blood lead test. Over 20% of the children tested in some US states had BLLs high enough to adversely affect learning and development.
Lead has been ubiquitous in the environment since the advent of industrialization. Major sources of environmental lead exposure are lead-based paint, lead-contaminated soil, occupational exposures, and industrial pollution. Lead can be found in some foods and drinking water from both natural sources and man-made pollution, ie, pipes and solder that contain lead. Lead-based paint remains the most common source of environmental lead exposure for children. The Consumer Product Safety Commission banned the manufacturing of most interior and exterior lead-based paint in 1978; however, leaded paint still remains a threat in many homes built before 1978. Also, lead-based paint is still available and currently used in industrial, military, and marine areas.
Nearly 1 million children in the United States have elevated BLLs. This problem is especially acute in certain population groups. For example, among children living in pre-1946 dwellings (when the use of lead in paint was most common), the prevalence of lead poisoning is 5 times higher than among children living in homes built after 1978 (most of which do not have lead paint). Interior surfaces that are likely sources of lead paint poisoning are trim-work, doorways, windowsills, and painted toys. Soil near painted buildings or roadways is often contaminated with lead and should be tested before being used for play areas or for planting edibles.
Hand-to-mouth activity and the efficiency of children's gastrointestinal absorption of lead-based paint dust place children at greater risk than adults. Adult lead exposure is a pediatric concern, as more than 1 million workers in more than 100 different occupations may be exposing their families to "take-home lead" if showers and changes of clothing are not provided at the end of a workday. Additionally, occupational exposures to pregnant women may cross the placenta and damage the developing nervous system of the fetus.
Physiologic effects of lead toxicity are noted in virtually every system. The central nervous system, hematopoietic and renal system, and vitamin D metabolism are significantly affected. Symptoms of lead toxicity can range from nonspecific complaints to irreversible and sometimes fatal damage to the central nervous system. Lower IQ, diminished speech and language processing, and decreased attention span are common effects of lead poisoning in children.
Symptomatic lead poisoning constitutes a medical emergency. Acute lead poisoning may be characterized by 1 or more of the following symptoms: headaches, clumsiness, anorexia, constipation, vomiting, agitation, bizarre behavior, apathy, and loss of developmental skills recently mastered. Central nervous system damage can progress to seizures and coma. Appropriate intensive care for very high-level lead poisoning can prevent death, but severe permanent brain damage is likely despite treatment.
Even low levels of lead are harmful. Levels as low as 10 micrograms of lead per deciliter of blood (mcg/dL) are associated with decreased intelligence, behavior problems, reduced physical stature and growth, and impaired hearing.[18,19] A child is estimated to lose 2 IQ points for each 10-mcg/dL increase in BLL. One study suggests that lead exposure may be associated with increased risk of juvenile delinquent behavior.[18,19]
Screening Homes for Lead Exposures
Nurses can perform dust sampling and/or train family and community members to sample for lead-based paint dust. There are also professional inspectors who can help homeowners make a lead assessment. The requisite "tools" for dust sampling are a tape measure, a baby wipe, and a sealed plastic bag.
Dust-wipe sampling for lead. Sample rooms where children spend the most time (bedroom, kitchen, playroom, etc); at the most used entrance door; where there are areas of failing paint; in areas where renovation is under way or planned. Sample spots in the room such as the inside windowsill; the window trough; the floor in front of the most used entrance.
Materials needed for lead sampling include:
The procedure for taking a sample is as follows:
Composite samples are sometimes required. Composite samples combine samples from several sites and provide an average exposure level. Composite sampling can help to identify lead-safe houses and indicate the need for further evaluation in homes where elevated lead levels are found. Points to keep in mind include:
Nurses' Role in Lead-Poisoning Prevention
Primary-prevention efforts involve identifying and eliminating lead hazards before children are poisoned. Until this can be achieved, screening and follow-up of lead-poisoned children is essential. Tests for BLLs are recommended for children at ages 1 and 2, and more frequently for children if they are at higher risk. Any home built before 1978 should be tested for lead exposure. Nurses and homeowners can test for lead dust or the presence of lead in the paint.
Education efforts can include the provision of information to parents regarding federal regulations (24 CFR Part 35, 40 CFR Part 745), which require that property sellers and landlords provide families with information about lead poisoning and about any known lead-based paint or lead hazards in a dwelling before its sale or lease.
The only way to prevent lead poisoning is to remove the source of exposure. However, the process of removal often creates more exposure. If lead-based paint is in good condition (as in not chipped, flaking, or in areas of high friction), it is safer and easier to simply cover the area with non-lead-based paint. The outermost paint surface should be lead-free. If there is lead-based paint underneath the intact paint, and the top surface is lead-free, there will not be an exposure unless the surface begins to deteriorate or if renovations or other activities are implemented that compromise the integrity of the paint.
Nurses should educate parents and local healthcare providers about lead poisoning and the importance of screening homes and children. Excellent materials exist from the EPA, the Alliance to End Childhood Lead Poisoning, and the National Safety Council. A helpful publication titled "Lead in Your Home: a Parents Reference Guide" can be accessed from the brochure and training section of the EPA Web site (see Related Resources).
Fatal Pediatric Lead Poisoning
On March 29, 2000, a 2-year-old girl was seen at a community hospital emergency department with a low-grade fever and vomiting for approximately 1 day. The child had been well since arriving in New Hampshire from Egypt with her Sudanese refugee family 3 weeks earlier. Laboratory findings included a microcytic anemia (hemoglobin: 7.6 g/dL; lower limit of normal: 11.5 g/dL) with occasional basophilic stippling of red blood cells. A throat swab streptococcal antigen screening test was positive. She was discharged from the emergency department with prescriptions for an antibiotic and antiemetic to treat her presumed strep throat. However, her vomiting worsened, and she was admitted to the same hospital on April 17, and then transferred to a tertiary-care hospital the next day. On April 19, approximately 5 hours after the transfer, she became unresponsive, apneic, and hypotensive. She was intubated and placed on a ventilator. Computerized tomography of the head showed diffuse cerebral edema and dilated ventricles. Later that day, the results of a blood test drawn on April 18 showed a BLL of 391 g/dL and an erythrocyte protoporphyrin level of 541 g/dL. Chelation therapy was initiated. Despite a decrease in her BLL to 72 g/dL and treatment for increased intracranial pressure, including surgical ventricular drainage, she remained comatose without spontaneous respirations, brain electrical activity, and intracranial blood flow. She was pronounced brain-dead on April 21.
An investigation revealed that after living in Egypt for approximately 18 months, on March 9, 2000, the family had moved to Manchester, New Hampshire, into an apartment constructed before 1920. A wall in a sibling's bedroom had multiple holes from which the patient had been seen removing and ingesting plaster. Two of 7 samples of plaster with the adhering surface paint contained lead at levels of 5% and 12%. Peeling paint (35% lead) was present on the balusters and floor (3% lead) of a porch outside the apartment entrance where the patient sometimes had played. She also had played near and looked out of a living room window that occasionally was opened during meal preparation. A wipe sample of dust from the window well showed 6732 mcg lead/square foot, well above the hazardous level of 800 mcg lead/square foot. The New Hampshire Department of Health and Human Services ordered the apartment owner to correct the lead hazards identified during the inspection. The patient's family relocated to another dwelling.
Mercury is another poisonous heavy metal that is a naturally occurring element. However, its increased presence in our environment is due to a variety of human pollutant sources. Most mercury pollution is released into the air and then falls directly into waterways or is deposited onto land where it can be washed into the water. Mercury concentrations in air are usually low and of little direct concern. When mercury is in water, however, biological processes transform it into a highly toxic form: methyl mercury. Methyl mercury bio accumulates in fish, with larger fish generally accumulating higher levels.
The Mercury-Fish Connection: FDA and EPA Advisories
Methyl mercury is a highly toxic compound and the fetus is extremely vulnerable to its toxicity. Women of childbearing age must be counseled about exposure to methyl mercury before and during pregnancy. In the past year, the FDA and the EPA have both issued advisory warnings for pregnant women advising them to limit their consumption of certain types of fish. The FDA advisories are for commercial fish and the EPA's advisories are for noncommercial fish. These advisories are based on the sometimes dangerously high levels of methyl mercury that are bioaccumulated in both freshwater and saltwater fish. Freshwater fish from contaminated waters have been shown to have particularly high levels of methyl mercury, posing potential risks for recreational anglers and people who regularly fish for food. A recent report by the National Academy of Sciences confirms that methyl mercury is a potent toxin, and concludes that children born to women who consume large amounts of fish during pregnancy are at greater risk for changes in their nervous system that can affect their ability to learn.
A recent report, titled "Brain Food: What Women Should Know About Mercury Contamination of Fish," asserts that the new fish advisories issued by the FDA, though a step in the right direction, are not protective enough. The report recommends that tuna steaks, sea bass, oysters, marlin, halibut, pike, walleye, and largemouth bass be added to the FDA's list of fish that should not be eaten by pregnant and nursing women or women of childbearing age. In addition, they recommend that the FDA advise women to eat no more than 1 meal per month of the following fish species combined: canned tuna, white croaker, mahi mahi, blue mussel, eastern oyster, cod, pollock, haddock, salmon from the Great Lakes, blue crab from the Gulf of Mexico, channel catfish (wild, not farmed), and lake whitefish.
Fish can be an important source of nutrition for the pregnant woman, developing baby, and young child. However, the following recommendations should be considered when choosing the type and amount of fish to consume. According to the EPA, if a woman is pregnant or could become pregnant, is nursing a baby, or is feeding fish to a young child, limit consumption of freshwater fish caught by family and friends to 1 meal per week. For adults, 1 meal is 6 ounces of cooked fish or 8 ounces of uncooked fish; for a young child, 1 meal is 2 ounces of cooked fish or 3 ounces of uncooked fish. Many states collect data on mercury levels in fish from local waters. Check with state or local health departments for specific advice on local waters where family and friends are fishing.
In addition, the FDA has issued an advisory on mercury in fish bought from stores and restaurants, which includes ocean and coastal fish as well as other types of commercial fish. The FDA advises that women of childbearing age and pregnant women, nursing mothers, and young children should not eat shark, swordfish, king mackerel, or tilefish. FDA also advises that women of childbearing age and pregnant women may eat an average of 12 ounces of fish purchased in stores and restaurants each week. Therefore, if in a given week a woman eats 12 ounces of cooked fish from a store or restaurant, then she should not eat fish caught by family or friends that week. This is important to keeping the total level of methyl mercury contributed by all fish at a low level. (See Related Resources for FDA Fish Advisory.)
Reducing Mercury in the Environment
The EPA and the states are working to reduce mercury pollution in the environment, but because methyl mercury is very persistent, it will be many years before methyl mercury levels in fish and the environment are reduced.
Coal-burning power plants are the single largest source of mercury pollution. Another significant source of mercury is from medical waste incineration because of the large quantities of mercury typically used in healthcare (eg, thermometers, sphygmomanometers, batteries, fluorescent lamps). The latter source is one in which nurses can have a direct influence. A national coalition of healthcare providers and others, called Health Care Without Harm, has launched an international campaign to eliminate mercury from use in the healthcare sector. The American Nurses Association is one of the more than 300 organizations involved in the campaign. See "Health Care Without Harm" in the Related Resources section for more information on mercury reduction in healthcare settings.
In addition, Hospitals for a Healthy Environment is a partnership program that also focuses in part on mercury reduction in hospitals (see Related Resources for their Web site).
Table 2 is a useful guide for detecting sources of mercury in the home and substituting them with mercury-free alternatives. It is not intended as an inclusive list, however.
Table 2. Hunt for Mercury at Home
Mercury has unique significance in some cultural practices. For example, in some ethnic folk remedies and in some religious practices, metallic mercury is used. It is described by several names, including "azogue," which can be found in stores called "botanicas" that specialize in items used in Esperitismo (a spiritual belief system of Puerto Rico), as well as voodoo and Santeria. In some Hispanic cultures, the use of azogue is recommended by spiritualists, card readers, and santeros, where the azogue is typically sealed in a pouch and recipients are advised to sprinkle it in their homes or cars. It may also be recommended by botanic owners to mix in bath water or perfume or place it in devotional candles.
In addition, there is some use of mercury-containing skin care products (soap, makeup, creams to lighten skin and hair) by Asian and African cultures. One study of a population in Tanzania discovered very high concentrations of mercury in women who used such products.Accident Spill Response
In the event of an accidental skin contact, recommendations are to remove contaminated clothing and to wash with soap and water. Eyes should be washed with water for at least 15 minutes, lifting both upper and lower lids, and then medical attention should be sought. If mercury is ingested or large quantities are inhaled, this constitutes a medical emergency and the person should be immediately seen in a clinical setting. See Related Resources for Accident Spill Response information.
Pesticides are chemical compounds that have been formulated to kill, control, or repel a pest. Pests come in many forms: weeds, insects, rodents, and microbes, including bacteria. As is true of all potentially hazardous chemicals, the resulting effects are dependent on the dose. Pesticides are associated with a host of health risks, including cancer and acute and chronic injuries to the respiratory, nervous, reproductive, immune, and endocrine systems. Some pesticides are formulated to biodegrade, but many persist in our environments. Children are particularly susceptible to pesticide exposure for all of the reasons that children are more vulnerable to all environmental exposures: Their "dose" per body weight is likely to be much higher, they consume more fruits and fruit juices (that may have pesticide residues), their metabolic rate is higher than adults', and they are more like to be on the ground (floors and lawns) where pesticides are likely to have been applied.
There is a growing body of scientific data about the harmful effects that pesticides have on children's health, both acute and chronic. Routes of exposure to pesticides include inhalation, ingestion, and dermal penetration. Eighty percent of exposures to pesticides occur indoors; measurable levels of up to a dozen pesticides have been found in the air inside of homes. Acute effects of exposure include eye and throat irritation, skin rashes, nausea, vomiting, diarrhea, headaches, flu-like symptoms, upper respiratory distress, and, in extreme cases, death.
Chronic effects, ie, those that appear long after exposure, include an increased risk of some types of cancer, reproductive impairment, and neurologic damage. Several studies have noted the relationship between childhood cancers (brain cancer, Ewing's sarcoma, Wilm's tumor, acute lymphoblastic leukemia, non-Hodgkin's lymphoma) and pesticide exposures.[28-32] The potential risks illustrated by these studies suggest a need for a precautionary approach when dealing with pesticide exposures generally, but especially with children.
The EPA is responsible for registering all pesticides and is currently conducting a review of older pesticides to ensure adherence to current scientific standards under the Food Quality Protection Act (FQPA). FQPA, signed into law in 1996, sets a tougher standard for pesticide use on food, with a focus on children's environmental health. There are more than 20,000 registered pesticide products, each formulated for a specific use or uses. In fact, the biocides that are now included in many hand-cleaning products are registered pesticides.
Instead of using pesticides, follow these tips to ward off insects and other pests in the home:
Integrated Pest Management
Integrated Pest Management (IPM) is really an approach to, rather than a rigid system for, pest control. It calls for the employment of the least hazardous methods for controlling pests before even beginning to think about the employment of potentially hazardous options. For example, incorporated into this approach is the removal of food and water sources from insects and/or other pests. Traditional pest control has relied heavily on pesticides as the first plan of attack. Integrated Pest Management differs in that it does not automatically rely on pesticide application. For more information, see Related Resources.
EPA Registration of Pesticides
All pesticides (insecticides, fungicides, etc., even biocidal soaps) must be registered with the EPA. Each registration is for a specific use, such as agricultural application (including specification of the type of plant to which it may be applied), home use, pet collars, and so on. If evidence emerges regarding ecologic or human health risks associated with a pesticide or a particular use of a pesticide, the EPA may ban it completely or withdraw its registration for a particular use. For example, chlorpyrifos (Dursban), a commonly used household pesticide, was banned in 2000 for household and garden use. It can still be used in agricultural settings (except on tomatoes), and it can still be used on "new homes" until 2005 for treatment of termites. (See Related Resources for Pesticide Product Recalls.)
Water is essential to life and comprises 60% to 70% of body weight. Children drink more water per body weight than adults. While the United States has made great efforts to provide safe and healthy water, not all drinking water is contaminant-free. Children, because of their special physiologic vulnerabilities and increased consumption of water, may be particularly sensitive to contaminants found in their drinking water. Contaminants may be microbial (virus, bacteria, protozoa), chemical, or radiologic. Nurses need to be aware of the quality of their patients' and community's drinking water and counsel those patients who may be more vulnerable to the contaminants in their water.
Millions of pounds of potentially hazardous industrial and agricultural chemicals are released into the environment each year in the United States. Some of the releases are intentional and some are accidental. Our drinking water, which is derived either from surface waters or from underground sources, are vulnerable to contamination from the pollutant releases, including agricultural and household chemicals, industrial waste, and uncontrolled releases from leaking underground storage tanks and landfills. Preventing source-water contamination should be incorporated as a community education concern.
In addition to chemical contaminants, pathogenic microbes account for an estimated 900,000 waterborne infections annually. The majority of waterborne disease incidence may be underestimated because not all outbreaks are recognized, investigated, or reported. Children exposed to microbial contaminants in drinking water may experience a range of gastrointestinal symptoms depending on their immune status and virulence of the microbe. Symptoms range from mild gastric distress to explosive diarrhea. Several microbial contaminants cause more than gastrointestinal symptoms. Exposure to the Coxsackie and ECHO viruses can lead to meningitis and encephalitis. In 1999, an outbreak of E coli 0157:H7 from contaminated drinking water led to 9 deaths in New York from toxic hemolytic uremic syndrome.
Chemical contaminants of particular concern for children include pesticides, heavy metals, nitrates, and disinfection by-products. Infants under the age of 6 months who are exposed to elevated levels of nitrites in drinking water (due to contamination from fertilizer use or sewage runoff) are at risk for developing "blue baby syndrome" (methemoglobinemia), a rare but life-threatening illness. Nurses, as primary health providers in the community, must be able to field questions about water quality and guide vulnerable populations to informed decisions.
The introduction of disinfectants to the drinking water supply was one of the greatest public health successes of the 20th century. Public drinking water is often disinfected by the addition of chlorine to the water during the treatment process. Although chlorine is effective in controlling many microorganisms, it forms organic chlorine compounds, referred to as disinfection byproducts, when it reacts with organic matter found in water distribution pipes. Epidemiologic studies indicate that there may be an increased risk of miscarriage in women and developmental effects to the fetuses of pregnant women exposed to high levels of these by-products.[36-38]
Although lead paint and dust are the primary sources of exposure to lead, lead in drinking water can contribute up to 20% of this amount. Lead can leach out of household plumbing (lead pipes and lead solder) or from older public water distribution pipes made of lead. In addition, boiling water for more than 1 minute may raise the concentration of lead and other heavy metals present in the water.
If lead is found in drinking water there are several options that should be considered:
A 1996 Amendment to the Safe Drinking Water Act allows consumers and their healthcare providers to have access to information concerning the quality of their drinking water. This Amendment requires public water system providers to produce and make available to consumers a Right to Know or Consumer Confidence Report (CCR). These reports are issued annually and must provide information on how to contact the water provider; the source of drinking water (river, reservoir, aquifer); any contaminants detected and their health effects; and compliance with federal drinking water standards. If people have not received their reports, they can call their water company or talk with their landlord to receive a copy. The reports include a recommendation for people with compromised immune systems to consult with their healthcare provider regarding appropriate precautions to take to avoid infection in the event of microbial contamination. Therefore, it is important to be informed about drinking water and who is more susceptible to microbial illness. The EPA has a Web site where many local CCRs can be found (see Related Resources for EPA Safe Water). A water supplier must notify its customers by newspaper, mail, radio, TV, or hand-delivery if water does not meet EPA or state standards or if there is a waterborne disease.
Largest Waterborne E coli O157:H7 Outbreak in United States History
In September 1999, 3-year-old Rachel Aldrich died after being infected with the toxic E coli O157:H7 strain at a New York county fair. Hundreds of others, including Rachel's sister, Kaylea, became ill as well. The New York Department of Health identified 71 people who were hospitalized during the outbreak. Of these, 14 developed hemolytic uremic syndrome, a severe complication of E coli O157:H7 infection that can lead to kidney failure. An investigation by epidemiologists identified 781 persons with confirmed or suspected illness (persons who developed symptoms) related to this outbreak. Of these, 127 cases of E coli and 45 cases of Campylobacter were confirmed by culture. (See Related Resources for International Bottled Water Association.)
Alternative Sources of Drinking Water
When a water source is considered unsafe because of a chemical, microbial, or radionuclide contamination, or because an individual is considered too vulnerable to drink tap water, tap water should be avoided. Alternatives include boiled water, bottled water, and treated or filtered water.
Boiled water. Most harmful microbes found in water will be killed if water is allowed to reach a full rolling boil for 1 minute. However, boiling water for more than 1 minute may concentrate some chemicals (such as lead, arsenic, and nitrates) and may cause some chemical contaminants to be released in the steam where they then can be inhaled.
Bottled water. More than half of all Americans drink bottled water; about a third of the public consumes it regularly. The National Resource Defense Council  completed a 4-year study to evaluate the quality of bottled water. They found that bottled water regulations are inadequate to assure consumers of safety. At least a third of the bottled water tested violated a state standard or guideline for microbials. The FDA is responsible for good manufacturing practices for bottled water; however, it does not have jurisdiction over intrastate commerce of bottled water, which exempts roughly 60% to 70% of bottled water from FDA regulation. In addition, FDA regulations do not apply to carbonated water. The following organizations can provide information on bottled water:
Water filters. There are a variety of water treatment units on the market. No one filter removes all sources of contamination; therefore, it is important to identify the contaminant(s) of concern before recommending or investing in a filtration device for the home. For help in picking a unit, contact either of the independent nonprofit organizations listed below. (Water treatment units certified by these organizations will indicate certification on their packaging labels.)
Tap Water Testing
Although public water utilities are required to test for regulated contaminants and report the results, there may be instances when consumers may want additional information. For example, consumers may want to check for lead in the water. Water utilities are not required to check the lead level at each end point. In addition, most states have some regulations regarding the water testing of new wells; however, there are seldom requirements for periodic retesting. Private wells are not regulated by the EPA as public utilities are, although EPA does recommend that private wells be tested annually.
The right to know statutes do not apply to personal wells. Therefore, consumers with private wells should have them checked annually for bacteria and some chemical contaminants, such as nitrates. Information for private well owners about how to protect a private water supply, as well as links to a list of state-certified drinking water laboratories, can be found in Related Resources for EPA, Info on Private Wells. In addition, most state health departments can provide a list of state-certified independent water testing laboratories. Prices for water testing vary according to the type and number of contaminants being detected.
NSF International is an organization that tests and verifies that
products they certify meet all of the requirements of specified standards
and that manufacturers' claims are true. NSF does not recommend, rate, or
compare products. An NSF mark indicates assurances that the product will
perform as claimed. NSF will issue certification to water bottlers that meet
the basic FDA requirements. If the product meets the NSF standards, the
bottled water label should indicate the certification. In addition, NSF will
issue certifications for water treatment devices if they meet NSF standards.
More information about this service can be found at the NSF Web site (see
Watch for UV Index reports in your local newspapers and on television. Information on the daily UV Index can usually be found in the newspaper. In addition, the UV Index is available for all communities across the United States in a zip code-searchable format (see Related Resources for EPA, UV Protection).
Children (and adults!) should be taught to protect themselves from the harmful effects of UV radiation. Here are tips that everyone should follow.
Limit time in the midday sun.The sun's rays are strongest between 10 am and 4 pm. Whenever possible, limit exposure to the sun during these hours.
Seek shade. Staying under cover is one of the best ways to protect a child from the sun. Remember the shadow rule: "Watch your shadow; no shadow, seek shade!"
Always use sunscreen. Choose a broad-spectrum sunscreen with a Sun Protection Factor (SPF) of at least 15 or higher. Apply it liberally to exposed skin and reapply it every 2 hours when working or playing outdoors. Even waterproof sunscreen can come off when you towel-dry, sweat, or spend extended periods of time in the water.
Wear a hat. A hat with a wide brim offers good sun protection to eyes, ears, face, and the back of the neck, areas particularly prone to overexposure to the sun.
Cover up. Wear tightly woven, loose-fitting, and full-length clothing.
Wear sunglasses that block 99% to 100% of UV radiation. Sunglasses that provide 99% to 100% UV-A and UV-B protection will greatly reduce sun exposure that can lead to cataracts and other eye damage. Check the label when buying sunglasses.
Avoid sunlamps and tanning parlors. The light source from sunbeds and sunlamps damages the skin and unprotected eyes. It's a good idea to avoid artificial sources of UV light.
Watch for the UV Index. Keep tabs on the UV Index (Table 3) so that you know how likely you or your child are to get a sunburn on a given day.
In our homes, there are a number of environmentally related health threats that can be avoided by good assessment activities and the removal of the threats. All homes should be tested for the presence of radon. In homes where fuel powers the heating system, furnaces should be inspected annually. Carbon monoxide detectors should be considered for homes in which gas fuels the furnace or stoves. Homes built before 1978 should be tested for lead-based paint. Nurses, as role models for their families and communities, should be the first to know whether such environmental health threats exist in their own homes; they should then include such assessments when they do home visits or prepare new moms and recovering patients for their return home from the hospital.
So many of the environmental health threats in homes can endanger children and their ability to learn. Working with daycare settings and schools to incorporate environmental health education can help to improve the community's knowledge about preventable environmental diseases. Nurses are uniquely qualified members of the community to initiate such educational and awareness programs.
According to a Roper poll (contracted by the National Environmental Education and Training Foundation,) on public knowledge, attitudes, and behavior, healthcare providers are among the most trusted sources of information about certain environmental health issues. It demands that we, as nurses, educate ourselves about the relationship between environmental exposure and potential human health effects so as to honor this trusted position that we hold with our patients and the community.
There are many great resources that nurses can access for additional information. A variety of Web sites, including EPA's, the National Library of Medicine's, and the University of Maryland School of Nursing's, all present information that has been screened for accuracy, as well as many more resources suggested in this Clinical Update.
Equally important, nurses need to be at the tables where environmental health policies are being made -- locally, at the state level, and nationally. The ANA has passed several resolutions, such as The Reduction of Health Care Production of Toxic Pollution Resolution (see Related Resources for Nursing World Organization), that focus on environmental health and have the potential for a significant presence on environmental health issues. Individual nurses and nursing professional organizations have a great potential to affect environmental health and make a difference in creating environmental health policies and practices that are protective for all, including our most vulnerable populations.
Copyright 2003 American Nursing Association
See also:Up | Environmental Marketing Ideas | Hygienists Resources | OSHA-Lead-Penalty | Healthy-Home-Fundamentals | Pollution-In-Humans | Where-Asbestos-Are | Dust-Mites | Earth-Drying-Up | Air-Pollution-Genetics | Office-Germs | Legionnaire-Disease | Workplace-Lung-Disease | Air-Filter-Effectiveness | Hotel-Pest-Liability | Smog-Exposure | Airline-Respirator-OHSA | Chromated-Copper-Arsenate | Hygiene-Cleanliness-Allergens | Toxic-Dust-Problems | Rocky-Mountain-Spotted-Fever | Drinking-Water-Problems | Smoking-Causes-Asthma | Road-Dust-Mold | Home-Pesticide-Hazard | Toxic-Pollution-Rises | Environmental-Friendly-Building | Toxic-Urinal-Deodorant | Cleaning-Product-Asthma | WTC-Environmental-Lawsuit | Traffic-Heart-Attack | Fragrances-Weaken-Immune | Hazard-Exposure-Pathway | Flood-Advice-Tips | Foodborne-Disease | Infectious-Intestinal-Diseases | Respiratory-Infection | OSHA-Compliance-Tips | Indoor-Pollution-Hazards | Excessive-Noise | Living-Near-Parks-Good | Site-Map | Bacterial-Glossary
Mold Inspector Mold