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Running Head: ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC

Andrew Godwin Environmental Chemical Hazards: Polycyclic Aromatic Hydrocarbons Nursing 467 Dynamic Integration-Health Promotion within the Community

Dunigan Family Department of Nursing and Health Sciences University of Evansville

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC November 7th, 2011 Determine Nature & Extent of the Problem Polycyclic aromatic hydrocarbons or PAHs are a collection of over 100 different chemicals that can cause a myriad of health problems for populations exposed (Polycyclic aromatic, 2011). These substances are most commonly released into the air as a result of burning organic materials such as coal, oil, gasoline, trash, tobacco, and wood. PAHs can also occur in the environment naturally from the emissions of forest fires and volcanoes. The everyday person can be exposed to PAHs most commonly by breathings in polluted air, wood smoke, car exhaust, and cigarette smoke ("Fourth national report," 2009). PAHs are left behind in soil where coal, wood, and petrol have been burned. Campsites are common locations for exposure, as one can easily be exposed to toxic chemicals in both the smoke from

the fire and from the soil in which the fire burns. Soil near city dumps and other hazardous waste sites is also likely to be contaminated with PAHs. At home, PAHs can be found in pesticides, medicines, drinking water, charred or grilled meats, and contaminated food. Herbal dietary supplements called charparral contain cresote bush leaves, which have natural concentrations of polycyclic hydrocarbons that can be toxic in excess or over an extended span of time. PAHs can effect populations of all ages. One population of high concern is children because they are generally weaker and are still developing. On a website constructed by USA Today entitled The Smoke Stack Effect (2009) it is reported that Newburgh Elementary, a school in Southern Indianas Warrick county ranks in the 9th percentile of schools breathing polluted air. That means that out of 127,809 elementary, middle, and high schools in the United States, only 10,005 have worse air quality. The report also stated that PAHs are responsible for a 17% contribution to the overall toxicity of the air pollution in the area of Southern Indiana. This

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC

is reason for concern, and notice for action to reduce the amount of toxic pollutants present in the air. Polycyclic aromatic hydrocarbons also pose a threat to a great number of occupations. Workers at risk for exposure to PAHs include those working at coal tar, aluminum, and asphalt production plants. Southern Indiana contains many of these industries, which employ thousands of people, all of whom are at increased risk for exposure. Other Southern Indiana workplaces that pose PAH exposure hazards include: smokehouses, foundries, automotive repair shops, farms using pesticides, transportation, road paving, roof tarring, and even cooking and catering. These professions work directly with products that contain or emit in to the air concentrations of polycyclic hydrocarbon compounds (Bosetti and Boffetta, and Vecchia, 2007). PAHs are associated with numerous health risks with long-term exposure. The most significant risk associated with long-term exposure is increased incidences of lung, skin, and bladder cancers (Bosetti et al., 2007). PAHs do not have a high degree of acute toxicity in humans on their own, but in PAH mixtures they are more volatile and likely to cause health problems. Animal studies show that certain PAHs can also affect the hematopoietic and immune systems and can produce reproductive, neurologic, and developmental effects (Zhao, 1990). Further research is needed to establish these concerns in humans. Since PAHs have low acute toxicity, other more acutely toxic agents probably cause the acute symptoms attributed to PAHs. Chemicals such as hydrogen sulfide in roofing tars and sulfur dioxide in foundries are examples of acutely toxic contaminants. Naphthalene is the most abundant toxic polycyclic aromatic hydrocarbon in coal tar. This PAH is a skin irritant, and its vapors may cause headache, nausea, vomiting, and diaphoresis (Rom, 1998). Side effects reported from occupational and long-term exposure are: chronic bronchitis,

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC chronic irritated cough, bronchogenic cancer, dermatitis, and photosensitivity. Occupational

exposure to coal tar-containing PAHs has been shown to result in: erythema, burns, and warts on sun-exposed areas, which can then progress to cancerous growths on the skin ("Fourth national report," 2009). The eyes may also become irritated and sensitive to light. Hematuria, kidney, and bladder cancers are genitourinary conditions linked to prolonged exposure to PAHs. The gastrointestinal system may be affected by PAHs causing leukoplakia, and oral cancers. Concepts of causation that can be attributed to the Southern Indiana area would include the large population of production plant workers that are chronically exposed to PAHs in the air they breath and in the materials they work with on a day to day basis. After years of exposure to PAHs, a generation of workers may very well have an increased incidence of cancers that are attributed to PAH exposure. Furthermore populations situated downwind from these massive production plants such as Alcoa, AK Steel, and Toyota are also at increased risk for exposure related illnesses. PAHs are believed to cause cancerous growth as the body breaks down the PAH chemicals into various metabolites; which then bind to a clients DNA causing a greater chance that their will be a error in cell replication (Bosetti et al., 2007). The error in cell replication is the mechanism of cancer. Tissues with rapid regeneration rates are most susceptible to the carcinogenic effects of PAHs. The genetics of a particular client may also influence how severely the person is affected by PAHs exposure, but this relationship is not yet understood. More demographic research needs to be compiled. If members of the community were exposed to PAHs it would likely be overtime and be in areas of increased air, water, and food pollution. If it were discovered that the public had been being exposed to significant amounts of PAHs over an extended period of time actions would need to be taken by the local health officials. These actions will be described in the Plan for

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC Control section of this paper. Data Analysis To begin addressing the problem assessment data must first be gathered. There are several pieces of statistical data that are relevant for analysis regarding long-term health effects caused by polycyclic aromatic hydrocarbon exposure. Firstly it would be prudent to gather

histories on the client population exposed. An accurate PAH exposure history can be a hint to the nurse or how severe the problem maybe. This is the most affordable and often reliable intervention. Chemical indicators would be useful data to be gathered. These are obtained via urinalysis, as the kidneys excrete PAH metabolites into the urine. These metabolites differ between various examples of polycyclic hydrocarbons. Urinary 1-hydroxypyrene levels are the most common levels to be evaluated. The hydroxylated metabolites are however not reliable indicators of toxicity as individuals experiencing similar exposures have been shown to display different levels of metabolites (Jacob and Seidel, 2002). Metabolites from PAHs may be able to be detected in the blood and tissues, but this is more costly and less common. This urinary bio monitoring of PAH metabolites provides physicians and public health nurses with reference values so that they can determine whether or not people have been exposed to higher levels of PAHs than are found in the general population. This data may also aid researchers plan and conduct experiments on the negative health effects associated with PAH exposure. On the flipside due to the poor understanding of the significance of these levels it is impossible to correlate specific illnesses with certain metabolite levels. The chemical can only be detected to prompt further investigation. It is also important for the nurse to gather statistical data concerning the air quality in the

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC

Southern Indiana region as well as the rates of disease that may be attributed to exposure of PAH chemicals. This gives the nurse an idea of the severity of the problem and what resources they need to implement. It is also necessary for the nurse to identify workplaces in the community that may have employees being exposed to PAH compounds. Gathering historical data regarding occupational and environmental exposures can help the nurse to assess probable sources of exposure. It will also aid in identifying which populations may be at higher risk of exposure. In the United States PAHs are of increasing concern. The Agency for Toxic Substances and Disease Registry or ATSDR ranked the impact of polycyclic aromatic hydrocarbons on the Nations air quality as 9th on their Substance Priority List (2011). The state of Indianas lung and bronchus cancer rates are higher compared to the national average. The rate of lung and bronchus cancer in Indiana between 2003 and 2007 was 67.2. Compare this to the national average of 54.8 and that is a nearly a 20% difference ("Indiana cancer fact," 2008). This piece of statistical data suggests that the citizens of Indiana may already be suffering from the cancer causing effects of PAHs in their environment. The overall cancer rates in Indiana are also slightly higher that the national average by about 3%. As stated before, the USA Today webpage entitled The Smoke Stack Effect (2009) reported that Newburgh Elementary, a school in Southern Indianas Warrick county ranks in the ninth percentile of schools breathing polluted air. These are all relevant pieces of data that support the hypothesis that Southern Indiana citizens are at increased risk for being exposed to PAHs. Plan for Control With the relevant data analyzed, the nurse must then design a prevention plan with the goal of reducing the amount of clients in the population directly affected by PAH exposure. The plan would be to educate various populations in the community that may be at risk for exposure.

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC The learner objectives for the clients would be geared toward understanding household and environmental sources of exposure to PAHs so they can be better avoided. The sessions would discuss smoking cessation, PAH related health effects, and behaviors that can reduce the risk of overexposure and PAH related disease. As a primary prevention strategy the nurse provides education on how to prevent PAH

exposure to a group of teenagers at a local middle school. The educational session would include information on where PAHs are commonly encountered. They would also be educated on the various PAH related health effects and discuss techniques that can reduce the risk of PAH exposure. The teenagers would additionally be told about negative behaviors to avoid because of PAH exposure, such as smoking cigarettes. It is important for the nurse to also devise secondary prevention techniques to help reduce the effects of exposure in the community. The nurse could work to arrange a urine metabolitescreening test that is available for a small fee for local production plant workers who are at increased risk of exposure. The nurse could then establish the PAH levels present in the community among a sample of occupational workers. The workers should also be given a headto-toe assessment with a detailed medical history. This will help to identify any symptoms of PAH toxicity that may be present. Tertiary prevention is also important to provide for the community regarding PAH exposure. The nurse educates clients who have been continually exposed to PAHs. Some exhibit symptoms, some are symptom free, and others have now been diagnosed with various cancers and PAH related illnesses. The nurse works with these clients by educating them on their increased risk for bronchogenic cancer and the increased toxicity of cigarette smoke that contain several PAHs. The nurse would educate the clients on what symptoms would prompt a visit to

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC their healthcare provider. These symptoms include: a bloody cough, unexplained weight loss, shortness of breath, increased fatigue, and reoccurring respiratory infections (Polycyclic aromatic, 2011). The nurse would also convey the importance of periodic evaluations for even

asymptomatic clients who have been exposed. This may promote earlier detection and treatment if disease is present. Evaluate Control Plan The nurse would evaluate the primary prevention intervention by having the participants complete a short written quiz at the end of the session. By judging the scores of the quizzes the nurse can deduce how much learning has taken place. Questions for the quiz may include What are household products that contain PAHs? and what are places one might be exposed to PAHs? Some of the questions are left open-ended and without multiple choices. This may allow the nurse insight into commonly held misbelieves. This secondary prevention intervention could be evaluated by recording the percentage of at risk workers in the community who showed up to the screening. The percentage would then represent how strong the sample is. If the sample data is well represented, it could go a long way in identifying problem areas in the communitys workplaces. The tertiary intervention would be evaluated by a short written quiz that would indicate to the nurse if the client had retained the knowledge presented in the lecture. Questions for the quiz may include What are signs that I need to report to the doctor? and How might I lower my risk for further complications? The nurse might also follow the exposed clients progression and document who becomes ill and who stays well. Due to the fact that it is nearly impossible to estimate the additional risk caused by PAH exposure it should be the nurses aim to maintain a balance between proper concern and unnecessary alarm.

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC Exposure Plan In the efforts to minimize the adverse health effects of PAH exposure, client treatment

would first include removing contaminated clothing and cleaning the exposed skin with soap and water. If the clients eyes are tainted then the nurse should use saline irrigation to cleanse the eyes, followed by an ocular assessment. It is also recommended that the client perform a pulmonary function and receive a chest x-ray. These tools can aid in diagnosing acute damage as well as serve as a point of comparison for future assessments. These comparison assessments could be used to track the possible progression of malignant cell growths. A client who is acutely exposed to PAHs may present to the emergency department with a number of symptoms. The client may have a new chronic cough with or without the presence of blood. After exposure from the air the client may also be in respiratory distress, feeling short of breath. The client may also feel fatigued and weak, though these are typically symptoms of longer-term exposure. They may not have PAH metabolites yet in their urine if they were only recently exposed. An appropriate nursing diagnosis for a patient acutely exposed to PAHs would be ineffective breathing pattern r/t compromised pulmonary function secondary to exposure to polycyclic aromatic hydrocarbons. This is the primary diagnosis because in the acute setting it the airway and respiratory is always of chief concern.

References (2008). Indiana cancer fact sheet. Retrieved from Indiana Cancer Consortium website:

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC http://indianacancer.org/resources/Indiana.doc.pdf (2009). Fourth national report on human exposure to environmental chemicals. Retrieved from U.S. Center for Disease Control and Prevention website: http://www.cdc.gov/exposurereport/pdf/FourthReport.pdf (2010). 2009 state fact sheet. Retrieved from U.S. Environmental Protection Agency website:http://www.epa.gov/cgibin/broker?

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view=STCO&state=18&SFS=YES&year=2009&_service=oiaa&_program=xp_tri.sasma cr.tristart.macro (2010). Polycyclic aromatic hydrocarbons. Retrieved from Centers for Disease Control and Prevention website: http://www.cdc.gov/exposurereport/data_tables/chemical_group_17.html (2011). The atsdr 2011 substance priority list. Retrieved from Agency for Toxic Substances and Disease Registry website: http://www.atsdr.cdc.gov/spl/ (2011). Polycyclic aromatic hydrocarbons (pahs). Retrieved from National Library of Medicine website: http://toxtown.nlm.nih.gov/text_version/chemicals.php?id=80 Bosetti, C., Boffetta, P., & Vecchia, C. (2007). Occupational exposures to polycyclic aromatic hydrocarbons, and respiratory and urinary tract cancers: A quantitative review to 2005. Annals of Oncology , (18). Jacob, J., & Seidel, A. (2002). Biomonitoring of polycyclic aromatic hydrocarbons in human urine. Chromatography, B(778). The smokestack effect: Toxic air and america's schools. (2009). USA Today, Retrieved from http://content.usatoday.com/news/nation/environment/smokestack/search/IN/~/Evansville /newburgh elementary/name/~/1/

ENVIROMENTAL CHEMICAL HAZARDS: POLYCYCLIC Zhao, X. L. (1990). Effects of benzo[a]pyrene on the humoral immunity of mice exposed by single intraperitoneal injection. Journal of Preventive Medicine, (24).

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