ACC Community Concerned About the Carcinogenic Effects of Lead Analysis

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Assignment 2- Risk Analysis Please read the article on Carcinogenic and non-carcinogenic health risk assessment of heavy metals in drinking water and answer the following questions 1a. Should the community be concerned about the carcinogenic effects of Lead? Why or Why not? .....3 pts 1b. Based on your finding from (1a), what do you recommend?...........2 pts 2a. How about the non-carcinogenic effects of Barium? Why or Why not?...........3 pts 2b. Based on your finding from (2a), what do you recommend?............2 pts 3. Please read both articles on: Carcinogenic and non-carcinogenic health risk assessment of heavy metals in drinking water and Communicable disease risk assessment Discuss the major differences between the two approaches used in the articles MethodsX 6 (2019) 1642–1651 Contents lists available at ScienceDirect MethodsX journal homepage: www.elsevier.com/locate/mex Method article Carcinogenic and non-carcinogenic health risk assessment of heavy metals in drinking water of Khorramabad, Iran Ali Akbar Mohammadia , Ahmad Zareib , Saba Majidic , Afshin Ghaderpouryd,** , Yalda Hashempoure , Mohammad Hossein Saghif , Abdolazim Alinejadg,**, Mahmood Yousefih , Nasrin Hosseingholizadehi, Mansour Ghaderpoorij,k,* a Department of Environmental Health Engineering, Neyshabur University of Medical Sciences, Neyshabur, Iran b Department of Health, School of Public Health, Social Determinant of Health Research Center, Gonabad University of Medical Sciences, Gonabad, Iran c Department of Environmental Health Engineering, Health Center, Qazvin University of Medical Sciences, Qazvin, Iran d Student Research Committee School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran e Department of Environmental Health Engineering, School of Health, Mazandaran University of Medical Sciences, Sari, Iran f Department of Environmental Health Engineering, School of Public Health, Sabzevar University of Medical Sciences, Sabzevar, Iran g Department of Public Health, Fasa University of Medical Sciences, Fasa, Iran h Department of Environmental Health Engineering, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran i PhD. Student of Health Education and Promotion, Department of Health Education and Promotion, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran j Department of Environmental Health Engineering, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran k Nutrition Health Research Center, Lorestan University of Medical Sciences, Khorramabad, Iran A B S T R A C T The continuous urbanization and industrialization in many parts of the world and Iran has led to high levels of heavy metal contamination in the soil and then on the surface and groundwater. In this study, the concentrations * Corresponding author at: Department of Environmental Health Engineering, School of Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran. ** Corresponding authors. E-mail addresses: ghaderpoory_a@yahoo.com (A. Ghaderpoury), azimalinejad@gmail.com (A. Alinejad), ghaderpoori.m@lums.ac.ir (M. Ghaderpoori). https://doi.org/10.1016/j.mex.2019.07.017 2215-0161/© 2019 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 1643 of 8 heavy metals were determined in forty water samples along distribution drinking water of Khorramabad, Iran. The ranges of heavy metals in this study were lower than EPA and WHO drinking water recommendations and guidelines and so were acceptable. The mean values of CDItotal of heavy metals concentrations in adults were found in the order of Zn > Ba > Pb > Ni > Cr > Cu > Cd > Mo. The health-risk estimation indicated that total hazard quotient (HQing + HQderm) and hazard index values were below the acceptable limit, representing no noncarcinogenic risk to the residents via oral intake and dermal adsorption of water. Moreover, the results of total risk via ingestion and dermal contact showed that the ingestion was the predominant pathway. This study also presents that the carcinogenic risk for Pb, Cr, Cd and Ni were observed higher than the acceptable limit (1  106). The present study will be quite helpful for both inhabitants in taking protective measures and government officials in reducing heavy metals contamination of urban drinking water.  The data analyzed in this study show a clear situation regarding the quality of drinking water in Khorramabad.  The results of this study can be used to improve and develop the quality of drinking water that directly affects the health of consumers.  The present study will be quite helpful for both inhabitants in taking protective measures and government officials in reducing heavy metals contamination of urban drinking water © 2019 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). A R T I C L E I N F O Method name: Application of carcinogenic and non-carcinogenic health risk assessment of heavy metals in drinking water Keywords: Heavy metals, Non-carcinogenic risk, Carcinogenic risk, Ingestion, Dermal contact Article history: Received 8 May 2019; Accepted 12 July 2019; Available online 19 July 2019 Specifications Table Subject area: More specific subject area: Method name: Name and reference of the original method: Resource availability: Environmental Science Drinking water monitoring and quality Application of carcinogenic and non-carcinogenic health risk assessment of heavy metals in drinking water Concentration and ecological risk of heavy metal in street dust of Eslamshahr, Iran. Human and Ecological Risk Assessment: An International Journal, 1-10 The data are available with this article. Method details Supply of healthy drinking water is necessary to human life, and safe drinking water should not cause a remarkable risk to human health. The increasing trend of water shortage has various negative impacts on economic development, human livelihoods, and environmental quality around the world [1–3]. Numerous contaminants, including heavy metals, organic and inorganic compounds, etc. may contaminate water. Among harmful and persistent contaminants found in water, a special emphasis is given to heavy metals [4,5]. Rapid economic development and industrialization in many parts of the world and Iran has led to high levels of heavy metal contamination in the soil and then in the surface and groundwater [6–10]. The heavy metals are released into the water naturally or via human activities [11,12]. Many heavy metals are the natural elements of the earth’s crust. Weathering and decomposition of metal rock and ores can transfer heavy metals in groundwater and have led to human exposure for the entire history of mankind [5,13,14]. The levels of metals vary significantly from the soil of one region to another [15]. Anthropogenic activities considerably affect the availability of heavy metals in the ecosystems. Heavy metals may be released into water the in large quantities via vehicle exhaust, poor waste disposal, fossil fuel combustion, fertilizer and pesticide application, untreated wastewater irrigation, and atmospheric precipitation from various human activities including mining, smelting operation, 1644 A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 agriculture, etc. which can influence human health by affecting on vegetation, food chain and water quality [16]. Once released into the drinking water, heavy metals can be taken into the human body through several pathways such as direct ingestion, dermal contact, inhalation, through mouth and nose [17]. Heavy metals in water can cause extensive damage to the ecological environment and consequently human health due to their unique characteristics such as toxicity, poor biodegradability and bioaccumulation [18–21]. Some heavy metals are detrimental for metabolisms in the human body, serving as both structural and catalytic constituents of proteins and enzymes, but can have adverse effects when the levels were greater than international guidelines [22]. During prolonged exposure, heavy metals can accumulate in target tissues such as brain, liver, bones, and kidneys in the human body resulting in serious health hazards, depending on the element and its chemical form [23]. Health risk assessment of heavy metals is usually performed to estimate the total exposure to heavy metals among the residents in a particular area. Risk assessment of contaminants in humans is based on a mechanistic assumption that such chemicals may either be carcinogenic or non-carcinogenic [24]. Generally, ingestion and dermal absorption are the major pathways of exposure in water environment [25,26]. In order to assess water quality in an area effectively, it is crucial to find possible human health impacts of contaminants in drinking water. The traditional technique for estimating health impacts is to directly compare the analyzed levels with guideline limits, but it is not adequately valid to provide comprehensive hazard levels and find contaminants of the most important [27]. Health risk assessment is an essential method for evaluating the possible health effects in water environments caused by numerous contaminants [28,29]. This method has been extensively utilized by many researchers in literature for the estimation of the adverse health effects possible from exposure to contaminated water [30,31]. Although ingestion is the predominant pathway of exposure to contaminants in drinking water, inhalation and dermal absorption should also be considered [24]. Most health risk estimations associated with human exposure to contaminants in soil, water, and air are based on the exposure methods presented by the USEPA [13]. With the increasing trend of population, economy, and industry growth in Iran, the study is required to determine the impacts of development on the surface and groundwater, before any preventive measures can be considered in the land-use systems and watersheds to decrease the contamination levels of heavy metals. The main objectives of the present research were to determine levels of eight heavy metals including Lead (Pb), Chromium (Cr), Cadmium (Cd), Molybdenum (Mo), Zinc (Zn), Copper (Cu), Barium (Ba), and Nickel (Ni) in the drinking water of Khorramabad city and estimate health risks of non-carcinogenic (Pb, Cr, Cd, Mo, Zn, Cu, Ba, and Ni) and carcinogenic (Pb, Cr, Cd, and Ni) metals with respect to daily drinking of groundwater and dermal pathways for general adults in the community. The results of our research may provide some insight into heavy metal contamination in water and are useful for inhabitants in formulating protective procedures and health professionals in reducing heavy metal contamination of water environment, and also serve as a basis for comparison to other areas both in Iran and worldwide. Materials and methods Study area description The geographic coordinates of the study area are 33 290 1600 N 48 2102100 E in DMS (Degrees Minutes Seconds), located in the Khorramabad city, Lorestan Province in the west of Iran. Khorramabad is situated in the Zagros Mountains with a warm and temperate climate. Natural springs are the main sources of water supply in this city. At the 2016 census, its population was 373,416. Average annual rainfall in this region is 488 mm. This city stands at an elevation of approximately 1147 m above sea level [32]. The location map of the study area is depicted in Fig. 1. Materials and sampling Analytical grade HNO3 purchased from Merck Company was used in this work. Deionized water was utilized for solution preparation and also for dilution objectives. All glassware was washed and A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 1645 Fig. 1. Location map of sampling sites in the distribution network. dried in an oven at 105  C. Sampling bottles were cleaned by rinsing in a metal-free soap and then by soaking in 10% HNO3 before sample taking. Finally, the bottles were washed with deionized water. Totally, forty water samples from 40 different sites along the distribution network were collected during 2017 in order to measure the levels of potentially toxic heavy metals such as Pb, Cr, Cd, Mo, Zn, Cu, Ba, and Ni in drinking water of Khorramabad city. These samples were then transported to the laboratory and stored at 4  C until analysis. Sample analysis The collected samples were analyzed for eight heavy metals including Pb, Cr, Cd, Mo, Zn, Cu, Ba, and Ni using standard methods for the examination of water and wastewater [33]. Concentrations of the heavy metals in all samples were measured using an inductively coupled plasma mass spectrometry (ICP-MS). The limit of detection (LOD) of individual metal was in the range 0.5–5 ng/L for water samples. Health risk assessment Non-carcinogenic analysis Risks of individual heavy metals. Risk assessment is defined as the methods of evaluating the probability of occurrence of any given probable amount of the harmful health impacts over a determined time period [34]. The health risk assessment of each contaminant is normally based on the estimation of the risk level and is classified as carcinogenic or non-carcinogenic health hazards [35]. To estimate the heavy metal contamination and potential carcinogenic and non-cancer health risk caused via ingestion and dermal absorption of heavy metals in the water of the distribution network of Khorramabad city, Hazard Quotients (HQ), Hazard Index (HI), and the Incremental Lifetime Cancer Risk (ILCR) were used. The studied group in this study was adults. Eq. 1 and Eq. 2 taken from the Environmental Protection Agency (USEPA) were applied to determine the Chronic Daily Intake (CDI) via ingestion and dermal absorption routes, respectively [25,36]. CDI ingestion ¼ Cw :DI:ABS:EF:EP BW:AT ð1Þ 1646 A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 Table 1 Parameters and input assumptions for exposure assessment of metals through ingestion and dermal pathways. Parameter Unit Heavy metal concentrations (Cw ) Daily average intake (DI) Skin-surface area (SA) Permeability coefficient (Kp) Exposure time (ET) Exposure frequency (EF) Exposure duration (EP) Conversion factor (CF) Body weight (BW) ABS Average time (AT) mg/L CDI dermal ¼ L/day Cm2 Cm/hour Hour/event Day/years Year L/cm3 Kg All Days Values Ingestion Dermal adsorption – 2.2 – – – 365 70 – – 18000 Pb, Cu, Ba 0.001, Cr, 0.002, Zn 0.006, Ni 0.0002 0.58 350 30 0.001 70 0.001 25550 70 0.001 25550 Cw :SA:Kp : ABS:ET:EF:EP:CF BW:AT ð2Þ Where, Cw (in mg/L) is the concentration of heavy metals in water, SA (in cm2 ) is the skin area available for contact, Kp (in cm/hour) is the permeability coefficient, ABS (unitless) is the dermal absorption factor, DI (in L/day) is the daily average intake of water in the area, ET (in h/event) is the exposure time, EF (in days/year) represents the annual exposure frequency, ED (in years) is exposure period, CF (in L=cm3 ) is the unit conversion factor, BW (in Kg/person) is body weight, and AT (in days) is the average time. The input assumptions and their values for computing the chronic daily intake through oral ingestion and dermal absorption are summarized in Table 1. The HQ for each heavy metal was estimated using the ratio of computed mean daily intake (ADI, mg/kg/day) of a metal ingested with contaminated water to the reference oral dose (RfD) through oral ingestion and dermal absorption for the residents. The sum of all HQs gives an estimation of total potential health risks or HI. The calculation of the HI caused by water is presented as (Eq. 3): HQ ¼ CDI RfD ð3Þ Where, CDI and RfD are expressed in mg/kg-day. The values of the RfD and cancer slope factor for different metals are listed in Table 2. Hazard Index (HI) for multiple heavy metals. To estimate the total potential non-carcinogenic health impacts caused by exposure to a mixture of heavy metals in water, the HI for several heavy metals was computed according to the EPA guidelines for health risk assessment [37,38] using following Eq. 4: Xn HI ¼ HQ ¼ HQ Pb þ HQ Cr þ HQ Cd þ HQ Mo þ HQ Zn þ HQ Cu þ HQ Ba þ HQ Ni ð4Þ k¼1 Table 2 Reference dose (RfD) and cancer slope factor (CSF) for different metals. Element Rdforal Rdfdermal CSF (kg/day/mg) Pb Cr Cd Mo Zn Cu Ba Ni 1.4 3 0.5 5 300 40 70 20 0.42 0.015 0.005 1.9 60 12 14 5.4 8.5 41 6.1 0.84 A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 1647 The computed HI is compared to standard values: there is the possibility that non-carcinogenic impacts may occur in the residents when HI > 1, while the exposed person is unexpected to experience evident harmful health impacts when HI < 1 [39]. Carcinogenic analysis The probable cancer risks due to exposure to a specified dose of heavy metal in drinking water can be computed using the ILCR [40]. The ILCR is defined as the incremental probability of a person developing any type of cancer over a lifetime as a result of twenty-four hours per day exposure to a given daily amount of a carcinogenic element for seventy years [41]. The following equation (Eq. 5) was commonly used for the calculation of the lifetime cancer risk: ILCR ¼ CDI :CSF ð5Þ Where, CSF is the cancer slope factor and is defined as the risk generated by a lifetime average amount of one mg/kg/day of carcinogen chemical and is contaminant specific. The permissible limits are considered to be 106 and Zn > Cu > Cr > Ni > Pb > Mo > Cd. Non-carcinogenic analysis Human health risk assessment comprises the determination of the nature and magnitude of adverse health effects in humans who may be exposed to toxic substances in a contaminated environment. In the present work, exposure and risk assessments were carried out based on the USEPA methodology. Human exposure to heavy metals principally occurs via pathways of drinking water, food, inhaled aerosol particles and dust [43]. The degree of toxicity of heavy metals to human health is directly related to their daily intake. However, ingestion via drinking water and dermal adsorption was considered in this study. The first step in the non-carcinogenic analysis is the calculation of chronic daily intake (CDI) values. As given in the Table 4, the mean levels of total CDI (CDItotal) in mg/kg-day are 1.00E-04 for Pb, 11.60E-04 for Cr, 1.34E-05 for Cd, 1.60E-05 for Mo,1.48E-03 for Zn, 2.13E-04 for Cu, 2.55E-03 for Ba, and 1.09E-04 for Ni. Therefore, the mean values of CDItotal of heavy metals concentrations for adults were found in the order of Zn > Ba > Pb > Ni > Cr > Cu > Cd > Mo. As seen in Table 5, all the studied heavy metals had total HQs below 1. Accordingly, the health risk estimation of Pb, Cr, Cd, Mo, Zn, Cu, Ba, and Ni revealed the mean HQs suggesting an acceptable level of non-carcinogenic harmful health risk in all samples taken from Khorammabed’s water distribution A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 1649 network. From the computation of total HQs, it can be concluded that the contribution of the eight metals to the non-carcinogenic health risk was in the order of Zn > Ba > Cr > Cu > Mo > Pb > Ni > Cd. Moreover, to estimate the total potential non-carcinogenic impacts induced by more than one metal, the HQ computed for each metal is summed and expressed as a Hazard Index (HI) [44]. The mean values of HI through ingestion and dermal adsorption as wells as total HI were obtained to be 3.31E-03, 2.15E-06, and 3.32E-03, respectively. It shows neglectable non-carcinogenic risk to residents ’ health as the value of HI is below 1. The values of HI for heavy metals of inhabitants in the study area are summarized in Table 5. Carcinogenic risk analysis Heavy metals (Pb, Cr (VI), Cd, and Ni) can potentially enhance the risk of cancer in humans [45,46]. Long term exposure to low amounts of toxic metals could, therefore, result in many types of cancers. Using Pb, Cr (VI), Cd, and Ni as carcinogens, the total exposure of the residents were assessed based on the mean CDI values given in Table 4. The carcinogenic risk assessment for adults is given in Table 6. The values of cancer slope factor (CSF) for different metals used for carcinogenic risk assessment are listed in Table 2. For one heavy metal, an ILCR less than 1  106 is considered as insignificant and the cancer risk can be neglected; while an ILCR above 1  10-4 is considered as harmful and the cancer risk is troublesome. For the total of all heavy metals through all exposure routes, the acceptable level is 1 10-5 [46–48]. Among all the studied heavy metals, chromium has the highest chance of cancer risks (mean ILCR 6.54  10-3) and nickel has the lowest chance of cancer risk (mean ILCR 9.16  10-5). The results of this research present that there was a cancer risk from the contaminants to residents through the cumulative ingestion and dermal contact routes in the drinking water of the region. Conclusions This study was conducted to evaluate the health risks of exposure to heavy metals along with the water distribution network of Khorramabad city in Iran. Risk assessment relevant for the present study comprises computations of carcinogenic and non-carcinogenic risk of water through ingestion and dermal contact pathways. The maximum and minimum concentrations of heavy metals measured were related to Ba (81.31 mg/L) and Cd (0.43 mg/L), respectively. The order of the heavy metals toxicity according to mean concentrations measured in drinking water of the studied area was: Ba > Zn > Cu > Cr > Ni > Pb > Mo > Cd. Themean values of CDItotal of heavy metals concentrations in adults were found in the order of Zn > Ba > Pb > Ni > Cr > Cu > Cd > Mo. The HQs for those routes of this work decline in the following order: ingestion > dermal adsorption, meaning that ingestion is the dominant pathway of exposure to every receptor. The mean values of HI through ingestion and dermal adsorption as wells as total HI were obtained to be 3.31E-03, 2.15E-06, and 3.32E-03, respectively. Among all the studied heavy metals, chromium has the highest chance of cancer risks (mean ILCR 6.54  103) and nickel has the lowest chance of cancer risk (mean ILCR 9.16  10-5). The present study will be quite helpful for both inhabitants in taking protective measures and government officials in reducing heavy metals contamination of urban drinking water. Declaration of Competing Interest The authors of this article declare that they have no conflict of interests. Acknowledgment The authors would agree and thank Professor Mehdi Zarrei in SickKids - hospital in Toronto, Canada for valuable comments and suggestions, allowing us to improve this paper. Also, the authors of this study thanks to the Lorestan University of Medical Sciences (LUMS) to support this project and the students involved in conducting the experiments. 1650 A.A. Mohammadi et al. / MethodsX 6 (2019) 1642–1651 References [1] A. Singh, R.K. Sharma, M. Agrawal, F.M. Marshall, Health risk assessment of heavy metals via dietary intake of foodstuffs from the wastewater irrigated site of a dry tropical area of India, Food Chem. Toxicol. 48 (2010) 611–619. [2] H.N. Saleh, M. Panahande, M. Yousefi, F.B. Asghari, G.O. Conti, E. Talaee, A.A. Mohammadi, Carcinogenic and noncarcinogenic risk assessment of heavy metals in groundwater wells in Neyshabur Plain, Iran, Biol. Trace Elem. 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Canniatti-Brazaca, Heavy metals in vegetables and potential risk for human health, Sci. Agric. 69 (2012) 54–60. [40] M.S. Sultana, S. Rana, S. Yamazaki, T. Aono, S. Yoshida, Health risk assessment for carcinogenic and non-carcinogenic heavy metal exposures from vegetables and fruits of Bangladesh, Cogent Environ. Sci. 3 (2017)1291107. [41] I. Gržeti c, A.R.H. Ghariani, Potential health risk assessment for soil heavy metal contamination in the central zone of Belgrade (Serbia), J. Serbian Chem. Soc. 73 (2008) 923–934. [42] G. Tepanosyan, N. Maghakyan, L. Sahakyan, A. Saghatelyan, Heavy metals pollution levels and children health risk assessment of Yerevan kindergartens soils, Ecotoxicol. Environ. Saf. 142 (2017) 257–265. [43] M. Di’az-Somoano, M.E. Kylander, M.A. Lo’pez-Anto’n, I. Suárez-Ruiz, M.R. Marti’nez-Tarazona, M. Ferrat, B. Kober, D.J. Weiss, Stable lead isotope compositions in selected coals from around the world and implications for present day aerosol source tracing, Environ. Sci. Technol. 43 (2009) 1078–1085. [44] U.E.P. Agency, Guidelines for the health risk assessment of chemical mixtures, Fed. Regist. 51 (1986) 34014–34025. [45] F. Tani, S. Barrington, Zinc and copper uptake by plants under two transpiration rates. Part II. Buckwheat (Fagopyrum esculentum L.), Environ. Pollut. 138 (2005) 548–558. [46] S. Cao, X. Duan, X. Zhao, J. Ma, T. Dong, N. Huang, C. Sun, B. He, F. Wei, Health risks from the exposure of children to As, Se, Pb and other heavy metals near the largest coking plant in China, Sci. Total Environ. 472 (2014) 1001–1009. [47] E. Wcisło, D. Ioven, R. Kucharski, J. Szdzuj, Human health risk assessment case study: an abandoned metal smelter site in Poland, Chemosphere 47 (2002) 507–515. [48] G. Yang, Y. Li, L. Wu, L. Xie, J. Wu, Concentration and health risk of heavy metals in topsoil of paddy field of Chengdu Plain, Environ. Chem. 33 (2014) 269–275. WHO/CDS/NTD/DCE/2007.4 Communicable disease risk assessment: protocol for humanitarian emergencies June 2007 © World Health Organization 2007 All rights reserved. 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. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 1 Contents Page Acknowledgements 3 1. Introduction 4 2. Communicable disease threats 4 3. Risk assessment framework 5 4. References 10 Annex 1. Indicators to define potential hazard for selected diseases 12 Annex 2. Risk assessment matrix 13 Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 2 Acknowledgements Edited by Dr John Watson, Dr Michelle Gayer and Dr Máire Connolly of the Programme on Disease Control in Humanitarian Emergencies (DCE), Communicable Diseases cluster (CDS/NTD). This document is a product of the Communicable Diseases Working Group on Emergencies (CDWGE) at World Health Organization (WHO) headquarters. The CD-WGE provides technical and operational support on communicable disease control to WHO Health Action in Crisis cluster (HAC), WHO regional and country offices, ministries of health, other United Nations agencies, and nongovernmental and international organizations. The Working Group includes the departments of Epidemic and Pandemic Alert and Response (EPR) and Control of Neglected Tropical Diseases (NTD) in the Communicable Diseases (CDS) cluster; Roll Back Malaria (RBM), Stop TB (STB) and HIV/AIDS in the HIV/AIDS, Tuberculosis and Malaria (HTM) cluster; departments of Child and Adolescent Health and Development (CAH) and Immunization, Vaccines and Biologicals (IVB) in the Family and Community Health (FCH) cluster; Food Safety, Zoonoses and Foodborne Diseases (FOS) and Public Health and Environment (PHE) in the Sustainable Development and Healthy Environments (SDE) cluster; Injuries and Violence Prevention (VIP) and Nutrition for Health and Development (NHD) in the Noncommunicable Diseases and Mental Health (NMH) cluster; Security and Staff Services (SES) in the General Management (GMG) cluster; and the Health Action in Crises (HAC) cluster and Polio Eradication Initiative (PEI). The following people were involved in the development and review of this document, and their contribution is gratefully acknowledged: Pino Annunziata HAC; Eric Bertherat, CDS/EPR; Sylvie Briand, CDS/EPR; Claire Lise Chaignat, CDS/NTD; Yves Chartier, SDE/PHE; Claire Chauvin, DGR/POL; Karen Ciceri CDS/NTD; Micheline Diepart HTM/HIV; Pierre Formenty, CDS/EPR; Dominique Legros, CDS/EPR; Pamela Mbabazi CDS/NTD; David Meddings, NMH/VIP; Angela Merianos, CDS/EPR; Tim Nguyen, CDS/EPR; Jose Nkuni, HTM/GMP; Salah Ottmani HTM/STB; Suzanne O'Rourke CDS/NTD; William Perea (CDS/EPR); Zita Weise-Prinzo (NMH/NHD). Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 3 1. Introduction Humanitarian emergencies caused by conflict or natural disasters, are frequently characterized by the displacement of large numbers of people, with severe disruption of basic infrastructure, resulting in overcrowding, increased exposure to disease vectors, food insecurity, and lack of access to safe water, sanitation, and basic health services. In populations affected by humanitarian emergencies, the risk of communicable diseases is greatly increased (1), with particularly high morbidity and mortality from communicable diseases in acute conflict situations (2). Death rates among displaced populations up to 10 that of baseline rates have been reported, with communicable diseases responsible for the majority of deaths (1). Diarrhoeal diseases, measles, malaria (in endemic areas), and acute respiratory infections are the most important causes of morbidity and mortality in displaced populations, particularly in the presence of high rates of malnutrition (1). Reducing this risk is a crucial part of protecting these highly vulnerable populations. A systematic assessment of the risk of communicable diseases, based on the best available evidence (risk assessment), is necessary to guide interventions designed to mitigate this increased risk (risk management). 2. Communicable disease threats The factors that influence exposure to, and facilitate transmission of, communicable diseases in emergency settings are well-described (1). The risk of communicable diseases is associated primarily with the size and characteristics of the displaced population: specifically, the amount and availability of safe water and functioning latrines; the nutritional status of the displaced population; the level of immunity to vaccine-preventable diseases such as measles; and the level of access to health care services (3). The risks to populations affected by humanitarian emergencies can be grouped together and assessed by disease category in a way that links to specific risks and interventions, as follows. 2.1 Water-borne diseases Large-scale population displacement often results in poor access to safe water and to adequate sanitation facilities, facilitating water-borne and food-borne transmission of pathogens. In these settings, diarrhoeal diseases such as cholera, typhoid fever and shigellosis can cause epidemics with high rates of mortality (4). Hepatitis E, which is also spread by the faecal–oral route, can result in jaundice and increased mortality in pregnant women (5). Furthermore, infection with leptospirosis is associated with displacement after flooding and the resulting proximity of rats to humans on shared high ground. 2.2 Vector-borne diseases Malaria is endemic in over 80% of areas affected by humanitarian emergencies (6). Weakened immunity due to malnutrition or co-infection, increased exposure to vectors owing to inadequate shelter and the collapse of health services can increase risk of death from malaria (6). Arboviruses such as dengue, yellow fever, Japanese encephalitis and Rift Valley fever; tick-borne illnesses such as Crimean–Congo haemorrhagic fever and typhus; and other vector-borne diseases such as plague are also endemic in areas affected by humanitarian emergencies. Increased exposure to vectors as a result of substandard housing can increase risk. Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 4 2.3 Diseases associated with overcrowding Measles, occurring in populations with low levels of immunization coverage, spreads easily in the crowded conditions associated with displacement, and outbreaks are common (1). Crowding can facilitate the transmission of meningococcal disease and may also contribute to the high prevalence of acute respiratory infections in displaced persons. Crowded living conditions can also aid the transmission of tuberculosis infection and diarrhoeal diseases. 2.4 Vaccine-preventable diseases In addition to measles and meningitis, displaced populations are at increased risk for vaccinepreventable diseases such as polio, tetanus, pertussis and diphtheria when levels of baseline immunization coverage are low. 2.5 Malnutrition Poor nutritional status compromises host immunity, leading to more frequent, prolonged and severe episodes of infections. Measles, diarrhoeal diseases, acute respiratory infections and malaria can result in high morbidity and mortality in malnourished populations (7). Additionally, public health programmes such as those for tuberculosis, malaria and HIV/AIDS are at risk of being disrupted by an acute humanitarian emergency. Rapid identification of those on treatment and prompt resumption of services are essential to ensure continuity of care. It is also crucial to reduce the risk of development and spread of drug-resistant strains such as multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDRTB). 3. Risk assessment framework The process of communicable disease risk assessment described here uses existing data to gauge both the likelihood and the impact of communicable diseases. Assessing risk is critical to identify priority interventions, to inform health planning, and to contribute to the reduction of morbidity and mortality in emergency-affected populations. At the World Health Organization (WHO), the Communicable Diseases Working Group on Emergencies (CD-WGE) uses available evidence and expert opinion to define the risk of communicable diseases (that is, the probability and impact of health effects from communicable diseases) in specific populations affected by humanitarian emergencies. The group consists of 28 technical experts representing the various disease units at WHO headquarters. The CD-WGE meets to assess the risks of communicable diseases in populations affected by humanitarian emergencies and, based on this, to prioritize interventions. Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 5 Figure 1. Standard operating procedures for developing a communicable disease risk assessment Event/Trigger Acute conflict or natural disaster, e.g. earthquake, flooding, tsunami Convene urgent CD-WGE meeting Real-time analysis of event, threats, risk: identify and quantify key communicable disease risks and interventions • Potential data sources o MoH national databases o WHO communicable disease epidemiological data summaries o WHO databases: WHO EMS, EPI summaries, WER, WHO global atlas database, UNAIDS, tuberculosis control annual reports, ioint WHO-UNICEF reports, etc. Technical note on communicable disease risk assessment and interventions • • • • 3.1 Circulate for technical review: CD-WGE, WHO regional/country office Date document for publication Distribute widely to partner agencies (Ministries of Health, WHO offices, UN agencies, NGOs, etc.) Upload to WHO web site (http://www.who.int/diseasecontrol_emergencies/guidelines/en/) Risk assessment framework: a three-step approach The potential for transmission of communicable diseases is influenced by a complex interplay of host, agent and environment. Accurately defining risk requires a careful consideration of the potential interactions of all three factors, in this case within the specific context of the area and population affected by the emergency. In response to an acute humanitarian emergency, the CD-WGE meets urgently to systematically review multiple sources of data (including existing data on outbreaks notified to WHO and other Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 6 disease programmes, relevant Ministry of Health data from affected countries and relevant published literature) in order to better define the risk of communicable diseases facing the emergency-affected populations (Figure 1). The CD-WGE undertakes a basic three-step approach when developing a communicable disease risk assessment (Table 1), modified from established risk assessment methods (8). The steps are event description, threat/vulnerability assessment, and risk characterization. Event description is the process of systematically assessing the type of emergency and the characteristics of the population displaced. Displacement caused by conflict, particularly when rates of malnutrition are high, generally carries a higher risk of mortality from communicable disease than displacement arising from natural disasters (3). The size of the displaced population and the duration of the displacement, among other factors, can influence the risk of transmission of communicable diseases. The process of threat/vulnerability assessment identifies potential interactions between the emergency-affected population (host factors), likely pathogens (agents) and exposures (environment) that determine factors that facilitate communicable disease transmission. Population factors include immunization coverage and underlying rates of malnutrition, as well as community practices such as use of bednets and boiling of drinking-water. Cultural practices, e.g. consumption of bushmeat or interaction with domestic animals, may also contribute to communicable disease risk. A comprehensive consideration of likely agents or pathogens is critical for the threat assessment. Specifically, endemic and epidemic-prone diseases (and their seasonality), the history of recent outbreaks and the communicable disease control programmes operating in the area must be considered. Indicators, such as those used to quantify burden of disease or programmatic impact, are also assessed (Annex 1). Environmental factors, such as shelter (amount, quality, location), availability of safe water and sanitation and access to basic health care services, can also strongly influence communicable disease transmission. The third step, risk characterization, uses a risk assessment matrix to analyse the available information on hazard and exposure for each disease under consideration (Annex 2). Both aspects of risk – the potential magnitude of the health impact and the likelihood of the event occurring – are approximately quantified and the overall risk is then characterized using the matrix. Based on the overall risk assessment, interventions for disease control are prioritized by evaluating additional factors such as cost, technology, availability and infrastructure requirements Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 7 Table 1. Three-step communicable disease risk assessment framework Step STEP 1 Event description Main qualitative assessment(s) • • Type of humanitarian emergency: conflict or natural disaster (flooding disaster, earthquake, tsunami) Characteristics of population displacement (size, duration, location, demographics, etc.) STEP 2 Threat/vulnerability assessment (host, agent, environment) Host: • Underlying malnutrition rates • Immunization coverage (e.g. measles, polio) • Community practices (e.g. use of bednets, boiling of drinking-water) • Community cultural practices (e.g. ritual slaughtering practices) • Availability of food Agent: • Endemic diseases present (e.g. malaria, Rift Valley fever) • Epidemic-prone diseases and recent epidemics (e.g. cholera, typhoid, meningococcal disease) • Ongoing communicable disease control efforts • Disease incidence, prevalence, seasonality (e.g. dengue, Japanese encephalitis, malaria) Environment: • Amount, quality and location of shelter • Availability of safe water and sanitation • Thermal extremes • Secondary toxic exposures • Available infrastructure for health and social services; access to basic primary health care services • Presence of vectors (and potential for proliferation) STEP 3 Risk characterization • Integration of information collected in Steps 1 and 2 into risk assessment matrix to estimate overall risk to population based the magnitude of potential impact and likelihood of a disease occurring using a risk assessment matrix (Annex 2) Very high: +++ High: ++ Low: + None: – No information available: N Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 8 The outcome is a concise, timely and population-specific profile of projected communicable disease risk, allowing evidence-based decision-making and focusing relief efforts on critical immediate actions. The event-specific technical note is entitled Communicable disease risk assessment and interventions. Using this mechanism, risk assessments have been performed for the Horn of Africa flooding disaster (9), the Middle East crisis (10) and the Indonesia earthquake (11) in 2006, and for the severe food shortage in Niger (12), the South Asian earthquake (13) and the Asian tsunami in 2005 (14). The CD-WGE mechanism focuses WHO technical capacity on reducing the risk and impact of communicable diseases on emergency-affected populations. The risk assessment framework used by the Working Group can inform the prioritization of interventions, identify priority diseases to guide surveillance and early warning strategies, inform health policies and ultimately improve the quality of data available for the ongoing protection of populations affected by humanitarian emergencies. Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 9 4. References 1. Connolly MA et al. Communicable diseases in complex emergencies: impacts and challenges. Lancet, 2004, 3(364):1974–1983. 2. Connolly MA, Heymann DL. Deadly comrades: war and infectious diseases. Lancet, 2002, 360:23–24. 3. Watson JT, Gayer M, Connolly MA. Epidemics after natural disasters. Emerging Infectious Diseases, 2007, 13:1–5. 4. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July 1994? Lancet, 1995, 11(345):339–344. 5. Aggarwal R, Krawczynski K. Hepatitis E: an overview and recent advances in clinical and laboratory research. Journal of Gastroenterology and Hepatology, 2000, 15:9–20. 6. Malaria control in complex emergencies: an interagency field handbook. Geneva, World Health Organization, 2005. 7. Caulfield LE et al. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. American Journal of Clinical Nutrition, 2004, 80:193–198. 8. National Research Council. Risk assessment in the federal government: managing the process. Washington, DC, National Academy Press, 1983. 9. Communicable disease risk assessment and interventions. Flooding disaster: Horn of Africa, December 2006. Geneva, World Health Organization, 2006 (WHO/CDS/NTD/DCE/2006.9; available from: http://www.who.int/diseasecontrol_emergencies/guidelines/flooding_hoa_3.pdf). 10. Guidelines for disease surveillance/early warning and response: Middle East crisis, August 2006. Geneva, World Health Organization, 2006 (WHO/CDS/NTD/DCE/2006.6; available from: http://www.who.int/diseasecontrol_emergencies/guidelines/Middle%20East%20Crisis_WHO%2 0CD%20surveillance_early%20warning%20guidelines.pdf). 11. Indonesia earthquake-affected areas. Communicable disease risks and interventions, May 2006. Geneva, World Health Organization, 2006 (WHO/CDS/NTD/DCE/2006.3; available from: http://www.who.int/diseasecontrol_emergencies/guidelines/Indonesia_post_earthquake_2.pdf). 12. Niger: communicable diseases risk assessment, July 2005. Geneva, World Health Organization (available from: http://www.who.int/diseasecontrol_emergencies/guidelines/Niger_risk_assessment.pdf). Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 10 13. South Asia earthquake-affected areas, 2005: operational plan and communicable diseases surveillance/early warning and response guidelines. Geneva, World Health Organization, 2005 (available from: http://www.who.int/diseasecontrol_emergencies/guidelines/asia_earthquake_early_warning.pdf). 14.Tsunami affected areas, 2005: communicable disease risks and interventions. Geneva, World Health Organization, 2005 (WHO/CDS/2005.34; available from: http://www.who.int/diseasecontrol_emergencies/guidelines/tsunami_risk_assessment.pdf). Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 11 Annex 1. Indicators to define potential hazard for selected diseases Malaria • • • • • • • • • • • • Measles • • Estimated population at risk Estimated population under 5 years of age at risk Estimated pregnant women at risk Reported malaria cases by year Reported malaria cases in children under five years of age by year Reported deaths attributed to malaria by year Estimated malaria deaths per year Estimated malaria incidence per 1000 population at risk per year Estimated malaria prevalence Population coverage, Insecticide-treated bednets/ indoor spraying of residual insecticide Resistance to anti-malarial drugs Resistance to insecticides Number of cases reported annually Immunization coverage (%), by year Meningococcal disease • Cases and deaths reported, by year • Recent epidemics and serogroups involved Yellow fever • Cases and deaths reported, by year • Recent epidemics • Estimated vaccine coverage (%) Poliomyelitis • Cases and deaths reported, by year • Recent epidemics • Estimated vaccine coverage (%) HIV/AIDS • Estimated number living with HIV/AIDS, by age and gender • HIV seroprevalence among ANC attendees • Estimated adult prevalence rate • Estimated number in need of ARV, including % children • Estimated number receiving ARV, including % children • National ARV regimen • Prevalence of HIV among adults with TB Tuberculosis • Number of TB cases notified, by year • Case notification rates per 100,000, by year • Number of new smear-positive cases, by year • Rate of new smear-positive cases per 100,000, by year • Monitoring indicators, for DOTS: new cases and re-treatment cases o Number of cases notified o Number of cases registered o % cured o % completed treatment o % died o % failed o % default o % success Malnutrition • Estimated size of at-risk population • Prevalence of moderate malnutrition (% of children with weight/height ratio of -3 Z-Scores) • Prevalence of severe malnutrition (% of children with weight/height ratio less than -3 Z-Scores) Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 12 Annex 2. Risk assessment matrix 3+ Potential magnitude 2+ of health impact 1+ 1+ 2+ 3+ Likelihood of event occurring Low risk High risk Very high risk Potential magnitude of health impact Severe (3+) High morbidity/mortality Moderate (2+) Excessive morbidity/mortality Low (1+) Minimal morbidity/mortality Likelihood of epidemic occurring High (3+) Endemic disease with potential for epidemic transmission clearly present; Widespread exacerbation of conditions favourable for communicable disease transmission; Highly susceptible population Moderate (2+) Endemic disease with potential for epidemic transmission present; Some exacerbation of conditions favourable for communicable disease transmission; High background levels of immunity but large number of susceptible people Low (1+) Endemic disease with potential for epidemic transmission possibly present; Conditions favourable for communicable disease transmission possibly present; Population largely immune Communicable Diseases Working Group on Emergencies, WHO Disease Control in Humanitarian Emergencies Program 13
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Running Head: RISK ANALYSIS

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Risk Analysis

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RISK ANALYSIS

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Risk Analysis

1a. Should the community be concerned about the carcinogenic effects of Lead? Why or
Why not?

Heavy metals including Cr, Ni, Pb, and Cd may cause cancer. If exposed to those kinds
of metals over an extended length of time, even a small amount can cause severe lethal effects.
Thus, the population and the community at large must be cautious about lead’s carcinogenic
properties.

1b. Based on your finding from (1a), what do you recommend?

As for myself, I believe that abstaining from such a water source is the best course of
action. Even if the heavy metals show an HQ of less than 1, they may have long-lasting
detrimental consequences.

2a. How about the non-carcinogenic effec...


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