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Concerns about adequate protection of children's health from chemicals in the environment have created a need for research to identify how children's risks differ from adults'. A systematic review of factors that affect child sensitivity throughout development may be useful for research and practice in this area. We summarized available literature and other peer-reviewed information on factors that affect pharmacokinetics and exposure in an age-based developmental framework. Biological processes related to chemical absorption (gastrointestinal, dermal, and pulmonary), distribution, metabolism, and excretion were considered, along with reference to behaviors and other factors associated with child-specific exposures. The available information was summarized in a timeline of maturation for biological processes. It indicates variability in the duration and timing of maturation for each biological function. Possible implications for understanding pediatric sensitivity to environmental chemicals are discussed in light of factors affecting exposure through development. Themes that emerge from the evidence are presented as hypothesis-generating conclusions. This approach may be useful for evaluating developmental trends of susceptibility, and for identifying time periods and/or chemical classes of particular concern and thus important to consider in risk assessment.

The microbiological contamination of drinking water supplies can have serious health consequences for consumers, and this has been dramatically illustrated in recent years by two disease outbreaks in Canada. In this paper, some factors that can influence the microbiological quality of drinking water and its management are examined. Frameworks have been proposed that help to clarify the main elements of health risk assessment and risk management, and, in accordance with these, risks can be logically characterized, evaluated and controlled. A protocol has been developed for microbiological risk assessment and a risk management framework now guides the development of Canada's national guidelines for drinking-water quality. Monitoring of indicator organisms and the application of adequate water treatment are the primary means recommended in the Canadian guidelines to safeguard health from the presence of water-borne pathogens. Understanding the biological characteristics of microbial pathogens is necessary for assessing their impact on community health and appraising the rationale behind drinking-water testing methods and their limitations. Improvements in health surveillance, monitoring, and risk characterization and application of concepts such as multiple barriers (source-to-tap) and total quality management should contribute to better management of the microbiological quality of drinking water.

An interdisciplinary workshop was convened by the George Washington University in June 2001 to discuss how to incorporate new knowledge about susceptibility to microbial pathogens into risk assessment and management strategies. Experts from government, academic, and private sector organizations discussed definitions, methods, data needs, and issues related to susceptibility in microbial risk assessment. The participants agreed that modeling approaches need to account for the highly specific nature of host-pathogen relationships, and the wide variability of infectivity, immunity, disease transmission, and outcome rates within microbial species and strains. Concerns were raised about distinguishing between exposure and dose more clearly, interpreting experimental and outbreak data correctly, and using thresholds and possibly linearity at low doses. Recommendations were made to advance microbial risk assessment by defining specific terms and concepts more precisely, designing explicit conceptual frameworks to guide development of more complex models and data collection, addressing susceptibility in all steps of the model, measuring components of immunity to characterize susceptibility, reexamining underlying assumptions, applying default methods appropriately, obtaining more mechanistic data to improve default methods, and developing more biologically relevant and continuous risk estimators. The interrelated impacts of selecting specific subpopulations and health outcomes, and of increasing model complexity and data demands, were considered in the contexts of public policy goals and resources required. The participants stated that zero risk is unattainable, so targeted and effective risk reduction and communication strategies are essential not only to raise pubic awareness about water quality but also to protect the most susceptible members of the population.

A total of 20 commercial cigarette and 16 commercial smokeless tobacco products were assayed for 96 25 compounds listed as harmful and potentially harmful constituents (HPHCs) by the US Food and Drug 26 Administration. For each product, a single lot was used for all testing. Both International Organization 27 for Standardization and Health Canada smoking regimens were used for cigarette testing. For those 28 HPHCs detected, measured levels were consistent with levels reported in the literature, however substan29 tial assay variability (measured as average relative standard deviation) was found for most results. Using 30 an abbreviated list of HPHCs, statistically significant differences for most of these HPHCs occurred when

Sequential serum samples collected from individuals at approximately 3, 8, and 13 months of age who were enrolled in a rotavirus vaccine study conducted in Washington, DC from October 1989 through January 1990, were analyzed for the presence of antibodies to the Norwalk, Hawaii, and Toronto strains of human calicivirus by an enzyme-linked immunosorbent assay. Antibodies were detected to the Hawaii, Norwalk, and Toronto viruses in 29 (85.3%), 24 (70.6%), and 27 (79.4%) of the serum samples, respectively, obtained from 34 children approximately one year following the final dose of rotavirus vaccine. Evidence was found for a high infection rate with these three viruses, with the highest frequency of serologic responses detected between the 8- and 13-month time points. During this period, 14 (42.4%), 13 (39.4%), and 16 (48.5%) of the 33 children tested showed evidence for a serologic response to Hawaii virus, Norwalk virus, and Toronto virus, respectively, as evidence by a 4-fold increase in antibody titer. O...

Risk factors for waterborne enteric infections are deduced primarily from outbreak surveillance data; however, in the United States, only a fraction of the estimated water-related outbreaks are reported through passive surveillance. In the past several years, advances in molecular detection techniques have furthered our knowledge about foodborne and waterborne causes of gastroenteritis, allowing the association of certain pathogens with biologic and exposure-related susceptibilities in their hosts. This article summarizes some of the recent data characterizing susceptibility to three common waterborne pathogens:Cryptosporidium, a protozoan; Norwalk-like virus; and the bacterium Escherichia coli O157:H7. The infectious dose of Cryptosporidium varies by several orders of magnitude by strain, and repeated low-level exposure in drinking water may be protective. Some people may be innately immune to Norwalk-like virus, despite multiple exposures. A major risk factor for E. coli O157:H7 infection is exposure to shallow groundwater sources contaminated with animal waste.

© 2017 The Author(s). Published by IOP Publishing Ltd. Background: Significant mitigation efforts beyond the Nationally Determined Commitments (NDCs) coming out of the 2015 Paris Climate Agreement are required to avoid warming of 2 °C above pre-industrial temperatures. Health co-benefits represent selected near term, positive consequences of climate policies that can offset mitigation costs in the short term before the beneficial impacts of those policies on the magnitude of climate change are evident. The diversity of approaches to modeling mitigation options and their health effects inhibits meta-analyses and syntheses of results useful in policy-making. Methods/Design: We evaluated the range of methods and choices in modeling health co-benefits of climate mitigation to identify opportunities for increased consistency and collaboration that could better inform policy-making. We reviewed studies quantifying the health co-benefits of climate change mitigation related to air quality, transportation, and diet published since the 2009 Lancet Commission 'Managing the health effects of climate change' through January 2017. We documented approaches, methods, scenarios, health-related exposures, and health outcomes. Results/Synthesis: Forty-two studies met the inclusion criteria. Air quality, transportation, and diet scenarios ranged from specific policy proposals to hypothetical scenarios, and from global recommendations to stakeholder-informed local guidance. Geographic and temporal scope as well as validity of scenarios determined policy relevance. More recent studies tended to use more sophisticated methods to address complexity in the relevant policy system. Discussion: Most studies indicated significant, nearer term, local ancillary health benefits providing impetus for policy uptake and net cost savings. However, studies were more suited to describing the interaction of climate policy and health and the magnitude of potential outcomes than to providing specific accurate estimates of health co-benefits. Modeling the health co-benefits of climate policy provides policy-relevant information when the scenarios are reasonable, relevant, and thorough, and the model adequately addresses complexity. Greater consistency in selected modeling choices across the health co-benefits of climate mitigation research would facilitate evaluation of mitigation options particularly as they apply to the NDCs and promote policy uptake.

The 2012 National Climate Assessment (NCA) has begun a systematic literature review of Climate Change (CC) and Human Health to include as a technical input for Health Sector Literature Review and B...

Children's behavior and physiology place them at unique risk from waterborne microbial and chemical contaminants. This article reveals children's susceptibility factors and the microbial and chemical contaminants of greatest importance to this age group. It also provides a primer on water treatment and alternatives to tap water. This article concludes with recommendations and resources to aid the practicing pediatrician in addressing patient concerns about drinking water.

Under the 1996 Amendments to the Safe Drinking Water Act (1), the U.S. Environmental Protection Agency (U.S. EPA) must consider susceptible subpopulations in its health risk assessments. The amendments mention specific groups, including young children, the elderly, pregnant women, and people who are immunocompromised by disease or treatment for diseases. The concept of susceptibility to adverse health outcomes from environmental exposures can be extended to other groups as well. For chemical exposures, a great deal of current research is the analysis of how differences in metabolic phenotypes modify the effects of toxic exposures. For microbial exposures, concepts of susceptibility have generally been limited to the permanent or transient protection from infection afforded by previous exposure. Little consideration has been given to the degree to which individuals may differ in the completeness of protection offered by their immune systems. In addition to genetic factors, nutritional status, systemic diseases, and toxic insult may alter the ability to mount an effective immune response. Social factors, such as access to health care, may also modify the course of infection with microbial pathogens. Risk assessment is an inherently multidisciplinary process, and yet the disciplines needed to address technical issues in microbial risk assessment (e.g., secondary spread, virulence) are not applicable to chemical risk assessment. Addressing this issue in a fresh, scientifically rigorous manner requires the interaction of scientists who have experience in conducting risk assessments with experts in recognizing, studying, and treating infectious diseases. On 30 November and 1 December 1999, the George Washington University's Center for Risk Science and Public Health (Washington, DC) convened a workshop titled "Incorporating Susceptibility into Microbial Risk Assessment." The goal of this workshop was to produce a consensus document with multidisciplinary input that defined susceptibility to microbial pathogens for the purposes of risk assessment and which provided a framework for incorporating data on susceptibility into microbial risk assessments. The specific objectives were to a) create a group process that effectively involved multiple disciplines, including those not traditionally involved in risk assessment, such as pathology and immunology; b) clarify the conceptual elements of susceptibility for the purposes of microbial risk assessment; c) identify the data sources for the elements of susceptibility in microbial risk assessment; and d) list the elements of susceptibility that need to be incorporated for different applications of microbial risk assessments.

Background The relation between occupational exposure and pancreatic cancer is not well established. A population-based case-control study based on death certificates from 24 U.S. states was conducted to determine if occupations/industries or work-related exposures to solvents were associated with pancreatic cancer death. Methods The cases were 63,097 persons who died from pancreatic cancer occurring in the period 1984–1993. The controls were 252,386 persons who died from causes other than cancer in the same time period. Results Industries associated with significantly increased risk of pancreatic cancer included printing and paper manufacturing; chemical, petroleum, and related processing; transport, communication, and public service; wholesale and retail trades; and medical and other health-related services. Occupations associated with significantly increased risk included managerial, administrative, and other professional occupations; technical occupations; and sales, clerical, and other administrative support occupations. Potential exposures to formaldehyde and other solvents were assessed by using a job exposure matrix developed for this study. Occupational exposure to formaldehyde was associated with a moderately increased risk of pancreatic cancer, with ORs of 1.2, 1.2, 1.4 for subjects with low, medium, and high probabilities of exposure and 1.2, 1.2, and 1.1 for subjects with low, medium, and high intensity of exposure, respectively. Conclusions The findings of this study did not suggest that industrial or occupational exposure is a major contributor to the etiology of pancreatic cancer. Further study may be needed to confirm the positive association between formaldehyde exposure and pancreatic cancer. Am. J. Ind. Med. 36:260–270, 1999. Published 1999 Wiley-Liss, Inc.

Nanotechnology has the potential to deliver considerable benefits to society. Some of the properties of nanomaterials, however, call into question the adequacy of current methods for determining hazard and exposure and for controlling risks. Given the limitations of existing regulatory tools and policies, three distinct initiatives are urgently needed: first, a major increase in nanomaterial risk research; second, rapid development and implementation of voluntary standards of care; and third, development of adequate regulatory policies on nanomaterial risk management.

While it has been recognized that actions reducing greenhouse gas (GHG) emissions can have significant positive and negative impacts on human health through reductions in ambient fine particulate matter (PM2.5) concentrations, these impacts are rarely taken into account when analyzing specific policies. This study presents a new framework for estimating the change in health outcomes resulting from implementation of specific carbon dioxide (CO2) reduction activities, allowing comparison of different sectors and options for climate mitigation activities. Our estimates suggest that in the year 2020, the reductions in adverse health outcomes from lessened exposure to PM2.5 would yield economic benefits in the range of $6 to $30 billion (in 2008 USD), depending on the specific activity. This equates to between $40 and $198 per metric ton of CO2 in health benefits. Specific climate interventions will vary in the health co-benefits they provide as well as in potential harms that may result from their implementation. Rigorous assessment of these health impacts is essential for guiding policy decisions as efforts to reduce GHG emissions increase in scope and intensity.

The federal government plays an integral role in supporting climate change science and health research in the USA. Federally funded climate change research initially focused on science to understand climate and earth systems change during the 1970s and 1980s. Today, federally supported climate change research involves numerous agencies pursuing a wide range of climate change science topics and applications, including research exploring the connections between human health and climate change. Because each federal agency has a different mandate and range of scientific expertise, the focus and goals of various agencies’ climate change and human health research vary. For example, the National Oceanic and Atmospheric Administration (NOAA) emphasizes the use of weather and climate forecasts and oceanographic data for public health applications, while the National Aeronautics and Space Administration (NASA) emphasizes health applications of remotely sensed data from its satellites. This chapter provides a brief history of federally funded climate research and includes a survey of the relevant agencies, programs, tools, and datasets to illustrate the diversity of health and climate change research supported by the federal government.

Background: Nearly 3 billion people worldwide rely on solid fuel combustion to meet basic household energy needs. The resulting exposure to air pollution causes an estimated 4.5% of the global burden of disease. Large variability and a lack of resources for research and development have resulted in highly uncertain exposure estimates. Objective: We sought to identify research priorities for exposure assessment that will more accurately and precisely define exposure–response relationships of household air pollution necessary to inform future cleaner-burning cookstove dissemination programs. Data Sources: As part of an international workshop in May 2011, an expert group characterized the state of the science and developed recommendations for exposure assessment of household air pollution. Synthesis: The following priority research areas were identified to explain variability and reduce uncertainty of household air pollution exposure measurements: improved characterization of spatial and temporal variability for studies examining both short- and long-term health effects; development and validation of measurement technology and approaches to conduct complex exposure assessments in resource-limited settings with a large range of pollutant concentrations; and development and validation of biomarkers for estimating dose. Addressing these priority research areas, which will inherently require an increased allocation of resources for cookstove research, will lead to better characterization of exposure–response relationships. Conclusions: Although the type and extent of exposure assessment will necessarily depend on the goal and design of the cookstove study, without improved understanding of exposure–response relationships, the level of air pollution reduction necessary to meet the health targets of cookstove interventions will remain uncertain. Citation: Clark ML, Peel JL, Balakrishnan K, Breysse PN, Chillrud SN, Naeher LP, Rodes CE, Vette AF, Balbus JM. 2013. Health and household air pollution from solid fuel use: the need for improved exposure assessment. Environ Health Perspect 121:1120–1128; http://dx.doi.org/10.1289/ehp.1206429

The Rio+20 United Nations Conference on Sustainable Development represents a crucial opportunity to place environmental health at the forefront of the sustainable development agenda. Billions of people living in low- and middle-income countries continue to be afflicted by preventable diseases due to modifiable environmental exposures, causing needless suffering and perpetuating a cycle of poverty. Current processes of economic development, while alleviating many social and health problems, are increasingly linked to environmental health threats, ranging from air pollution and physical inactivity to global climate change. Sustainable development practices attempt to reduce environmental impacts and should, in theory, reduce adverse environmental health consequences compared to traditional development. Yet these efforts could also result in unintended harm and impaired economic development if the new "Green Economy" is not carefully assessed for adverse environmental and occupational health impacts. The environmental health community has an essential role to play in underscoring these relationships as international leaders gather to craft sustainable development policies. A Conferência da ONU Rio +20 sobre desenvolvimento sustentável representa uma oportunidade crucial para colocar a saúde ambiental à frente da agenda de desenvolvimento sustentável. Bilhões de pessoas que vivem em países de baixa e média renda continuarão a ser afligidas por doenças evitáveis devido a exposições ambientais modificáveis causando sofrimento desnecessário e perpetuando um ciclo de pobreza. Processos de desenvolvimento econômico atuais, enquanto aliviam muitos problemas de saúde e sociais, estão cada vez mais ligados a ameaças de saúde ambiental, abrangendo desde poluição do ar e inatividade física até mudanças climáticas globais. Práticas de desenvolvimento sustentável tentam reduzir o impacto ambiental e deveriam, em teoria, reduzir as consequências adversas da saúde ambiental em relação ao desenvolvimento tradicional. Ainda assim, esses esforços podem também resultar em danos não intencionais e em pior desenvolvimento econômico se a nova "Economia Verde" não for cuidadosamente avaliada para impactos na saúde ambiental e ocupacional adversos. A comunidade da saúde ambiental tem um papel essencial para desempenhar, enfatizando estas relações enquanto líderes internacionais se reúnem para criar políticas de desenvolvimento sustentável.

Increasing urban green and blue structure is often pointed out to be critical for sustainable development and climate change adaptation, which has led to the rapid expansion of greening activities in cities throughout the world. This process is likely to have a direct impact on the citizens’ quality of life and public health. However, alongside numerous benefits, green and blue infrastructure also has the potential to create unexpected, undesirable, side-effects for health. This paper considers several potential harmful public health effects that might result from increased urban biodiversity, urban bodies of water, and urban tree cover projects. It does so with the intent of improving awareness and motivating preventive measures when designing and initiating such projects. Although biodiversity has been found to be associated with physiological benefits for humans in several studies, efforts to increase the biodiversity of urban environments may also promote the introduction and survival of vector or host organisms for infectious pathogens with resulting spread of a variety of diseases. In addition, more green connectivity in urban areas may potentiate the role of rats and ticks in the spread of infectious diseases. Bodies of water and wetlands play a crucial role in the urban climate adaptation and mitigation process. However, they also provide habitats for mosquitoes and toxic algal blooms. Finally, increasing urban green space may also adversely affect citizens allergic to pollen. Increased awareness of the potential hazards of urban green and blue infrastructure should not be a reason to stop or scale back projects. Instead, incorporating public health awareness and interventions into urban planning at the earliest stages can help insure that green and blue infrastructure achieves full potential for health promotion.Keywords: urban planning; urban wildlife; green infrastructure; blue infrastructure; ecossystem services; biodiversity; risk management; infectious diseases; climate change; adaptation(Published: 27 November 2015)Citation: Infection Ecology and Epidemiology 2015, 5: 30082 - http://dx.doi.org/10.3402/iee.v5.30082

This pilot project, carried out under the National Strategies for Health Care Providers: Pesticides Initiative, assessed the attitudes, beliefs and practices of pediatricians, nurse practitioners, physicians assistants, and nurses in the metropolitan Washington, D.C., area and the surrounding rural counties regarding health effects of pesticide toxicity and continuing education on pesticide toxicity in the years 2001-2002.Data were collected from practitioners (physicians, physician assistants, and nurse practitioners) and nurses using questionnaires as well as from practitioners using focus groups. Sites for questionnaire distribution and focus groups were selected to represent a variety of practice types and geographic settings. One-hundred-sixty questionnaires from practitioners and 43 from nurses were analyzed. These issues were probed further in six focus groups with 29 participants.Most respondents in both groups did not frequently diagnose or ask questions about pesticide toxicity on patient histories. Most focus group participants were more comfortable answering questions about acute pesticide toxicity, and many relied on poison control centers for assistance with management of acute cases. They expressed less understanding and more uncertainties about chronic toxicity. When asked questions by patients, 64% of practitioners and 69% of nurses felt poorly prepared to answer them. Forty percent of practitioners but only 26% of nurses felt it was important to obtain more information on pesticides. There were divergent preferences on ways to obtain continuing medical education (CME) in general, but a recurrent theme was the need to make CME on pesticide toxicity clinically relevant and one topic among several in a CME conference. Lectures and short courses were the most commonly preferred modes of education among both practitioners and nurses.Educational materials to reach this population of pediatric clinicians on pesticides, as well as other environmental health topics, should make the case justifying the importance of the topics, highlight information of clinical relevance, and use a variety of media. These results should be confirmed before being generalized to a broader group of clinicians, although the consistency of findings between focus groups suggests they are robust, at least for this geographic area.

Exposure to indoor air pollution from household burning and solid fuels affects nearly half of the world's population.

The Clean Air Act mandates that sensitive subpopulations be considered in setting standards to protect the public's health. The purposes of this paper are to point out different conceptualizations of susceptibility, examine how it is approached in risk-related processes, and recommend ways it may be more explicitly framed for risk assessment and management purposes. We studied the traditional risk assessment paradigm, the U.S. Environmental Protection Agency (EPA) guidelines and revised PM standard, discussions from recent interdisciplinary meetings, and peer-reviewed literature. Areas of controversy include what factors intrinsic and extrinsic to the host should be incorporated in susceptibility, what health endpoints are of concern, whether susceptibility is deterministic or stochastic, and whether it should be defined on an individual or population scale. Recent discussions about susceptibility applied to PM indicate that it needs to be more clearly defined and evaluated for scientific and policy purposes. We conclude that varying concepts of susceptibility can affect risk-related processes such as PM standard setting. We recommend that susceptibility be clearly defined in the problem statement of risk assessments and be addressed in a specific subsection of risk characterization, integrating all susceptibility findings from the prior three steps in the risk assessment paradigm.

The 55 countries participating in the U.S. Country Studies Program are using a variety of methods to assess their vulnerability to climate change and the potential for implementing adaptation options. Many of the countries are using models and methodologies provided by the U.S. Country Studies while others are using other methods and methodologies (Table 2.1). In all cases the countries are adapting the models and methodologies to their unique national circumstances. This chapter briefly describes those models and methodologies made available by the U.S. Country Studies Program. Readers will not find these models and methodologies described elsewhere in this report.

Robinson and Baumgartner reference recent studies showing that when individuals living in poverty receive new products such as bednets or water purifiers at no cost, their use patterns are similar to those who have purchased the same products ([ 1 ][1], [ 2 ][2]). Robinson and Baumgartner suggest that the same may be true for cookstoves. We agree that, especially for the poorest of the poor who are not currently paying for cooking fuels or fully engaged in a market economy, this may well be true. We eagerly await similar studies to confirm or deny this hypothesis for cooking solutions that offer improvement in indoor air quality, with the understanding that the effectiveness of the approaches will be specific to regional and cultural contexts. However, cookstoves and fuels are different from bednets and water purifiers in a variety of ways. Cookstoves, unlike bednets and water purifiers, are an essential household technology that virtually all potential consumers already possess in some form. In addition, the associations between cookstoves and illness may not be as readily apparent as those between mosquitoes and malaria or impure water and diarrheal diseases. The health impacts from indoor smoke may be too far in the future to influence choice. On the other hand, more efficient stoves can offer an immediate benefit to users by reducing fuel costs, a savings to households that bednets and water purifiers cannot make as readily. We agree that randomized controlled trials (RCTs) provide an excellent opportunity to answer questions about the relative effectiveness of different finance and dissemination approaches. RCTs, in combination with other research approaches, will be critical to understanding the interrelated social, behavioral, and economic determinants of successful implementation programs. 1. [↵][3] 1. J. Cohen, 2. P. Dupas , Q. J. Econ. 125, 1 (2010). [OpenUrl][4][CrossRef][5][Web of Science][6] 2. [↵][7] 1. N. Ashraf, 2. J. Berry, 3. J. M. Shapiro , Am. Econ. Rev. 100, 2383 (2010). [OpenUrl][8][CrossRef][9][Web of Science][10] [1]: #ref-1 [2]: #ref-2 [3]: #xref-ref-1-1 "View reference 1 in text" [4]: {openurl}?query=rft.jtitle%253DQ.%2BJ.%2BEcon.%26rft.volume%253D125%26rft.spage%253D1%26rft_id%253Dinfo%253Adoi%252F10.1162%252Fqjec.2010.125.1.1%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: /lookup/external-ref?access_num=10.1162/qjec.2010.125.1.1&link_type=DOI [6]: /lookup/external-ref?access_num=000274626700001&link_type=ISI [7]: #xref-ref-2-1 "View reference 2 in text" [8]: {openurl}?query=rft.jtitle%253DAm.%2BEcon.%2BRev.%26rft.volume%253D100%26rft.spage%253D2383%26rft_id%253Dinfo%253Adoi%252F10.1257%252Faer.100.5.2383%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [9]: /lookup/external-ref?access_num=10.1257/aer.100.5.2383&link_type=DOI [10]: /lookup/external-ref?access_num=000285141700017&link_type=ISI

Physicians and medical centers are the front lines of the battle against antibiotic resistance in infectious bacteria. Government agencies, professional organizations, and health care corporations have developed various directives and control mechanisms to help guide physicians toward prescribing practices that minimize the development and dissemination of antibiotic resistance. But as Jeffrey Ritterman, MD, points out in “Preventing Antibiotic Resistance: The Next Step,” (page 35) the quantity of antibiotics routinely administered to livestock and poultry as feed additives appears to dwarf human use. The evidence that using antibiotics as feed additives contributes significantly to the problem of antibiotic resistance in humans has been acknowledged by the major medical associations, including the American Medical Association, American Academy of Family Physicians, American Academy of Pediatrics, and dozens of others, leading them to call for an end to this practice. No economic sector is as directly affected by the challenge of antibiotic resistance as the health care sector. Physicians have taken many necessary steps to curtail unnecessary uses of antibiotics in humans, but what can they do about antibiotic practices on farms? Plenty. Doctors provide a trusted, authoritative voice to the public. Greater awareness of this misuse among physicians can translate into greater awareness and concern among their patients. And an educated, mobilized public can help counter industry denial and government inaction. Just as important is the role physicians play as leaders within medical centers and other large health care institutions. Medical centers have an impact on society that goes well beyond the health services they provide. They are universally among the largest employers in any given region: Kaiser Permanente (KP), as an example, has been the largest private sector employer in Los Angeles County for the past three years. Over the past decade, medical centers have recognized their significant role and responsibility in broader environmental and societal issues through organizations like Health Care Without Harm (HCWH) and Hospitals for a Healthy Environment (H2E). These organizations are reducing the health care industry's environmental footprint and changing markets by getting medical centers to adopt standards and purchasing policies to minimize use of toxic materials, such as mercury. With 140,000 employees, 30 medical centers and over 8 million enrolled patients, KP's actions and policies will influence the nation's economy. And among health care institutions, KP is known as a pioneering leader. KP's adoption of a purchasing policy that minimizes use of antibiotics in agriculture would help educate other hospitals, food services, and members of the public about the need to take similar steps. The adoption of purchasing policies that curtail antibiotic overuse in food animals—notably use of medically important antibiotics as feed additives—is already affecting the market. Environmental Defense has helped McDonald's (the world's largest meat purchaser), as well as Compass America and Bon Appetit (two of the nation's largest food-service companies) craft policies that restrict certain antibiotic uses in chicken. The Compass America policy also addresses the use of antibiotic feed additives in pork.2 While these policies are only first steps, they are having some real impacts. Indeed, earlier this year USA Today1 reported that several of the nation's largest chicken producers had dramatically cut their overall antibiotic use; Tyson's reported a drop of 93%. However, it's not clear to what extent similar steps have been taken throughout the chicken industry, and there is still much to be done in reducing antibiotic use in pork, cattle, and other food animals. It's possible that we are approaching a tipping point on this issue, but we are not there yet. Moreover, there are no regulatory or legislative guarantees that any of the progress made so far in reducing nonessential antibiotic use will be maintained. This is why it's so important for the medical profession and the health care sector to put their money where their mouths are, so to speak, and join these major food companies in setting purchasing policies to move the market away from routine uses of antibiotics in food animals. No economic sector is as directly affected by the challenge of antibiotic resistance as the health care sector. And no other sector's action has the same authority and influence on this issue. As comedian Marty Feldman has said, “the pen is mightier than the sword and much easier to write with.” Physicians, while restraining their pens from writing unnecessary antibiotic prescriptions, should employ them to help move the food industry away from unnecessary antibiotic use in food animals.

Climatic factors influence the emergence and reemergence of infectious diseases, in addition to multiple human, biological, and ecological determinants. Climatologists have identified upward trends in global temperatures and now estimate an unprecedented rise of 2.0 degrees C by the year 2100. Of major concern is that these changes can affect the introduction and dissemination of many serious infectious diseases. The incidence of mosquito-borne diseases, including malaria, dengue, and viral encephalitides, are among those diseases most sensitive to climate. Climate change would directly affect disease transmission by shifting the vector's geographic range and increasing reproductive and biting rates and by shortening the pathogen incubation period. Climate-related increases in sea surface temperature and sea level can lead to higher incidence of water-borne infectious and toxin-related illnesses, such as cholera and shellfish poisoning. Human migration and damage to health infrastructures from the projected increase in climate variability could indirectly contribute to disease transmission. Human susceptibility to infections might be further compounded by malnutrition due to climate stress on agriculture and potential alterations in the human immune system caused by increased flux of ultraviolet radiation. Analyzing the role of climate in the emergence of human infectious diseases will require interdisciplinary cooperation among physicians, climatologists, biologists, and social scientists. Increased disease surveillance, integrated modeling, and use of geographically based data systems will afford more anticipatory measures by the medical community. Understanding the linkages between climatological and ecological change as determinants of disease emergence and redistribution will ultimately help optimize preventive strategies.

Extreme weather events have revealed the vulnerability of health care facilities and the extent of devastation to the community when they fail. With climate change anticipated to increase extreme weather and its impacts worldwide—severe droughts, floods, heat waves, and related vector-borne diseases—health care officials need to understand and address the vulnerabilities of their health care systems and take action to improve resiliency in ways that also meet sustainability goals. Generally, the health sector is among a country’s largest consumers of energy and a significant source of greenhouse gas emissions. Now it has the opportunity lead climate mitigation, while reducing energy, water, and other costs. This Special Report summarizes several initiatives and compares three toolkits for implementing sustainability and resiliency measures for health care facilities: the Canadian Health Care Facility Climate Change Resiliency Toolkit, the U.S. Sustainable and Climate Resilient Health Care Facilities Toolkit, and the PAHO SMART Hospitals Toolkit of the World Health Organization/Pan American Health Organization. These tools and the lessons learned can provide a critical starting point for any health system in the Americas.