Don’t Overlook Assessing Environmental Exposures—During a Disaster and Every Day

Moderator: Marcia Friedman

Presenters: Marya G. Zlatnik, MD, MMS; Diane E. Hindman, MD PharmD, BScPhm; Perry Sheffield, MD, MPH; Brian Tencza M. Ed.

Date/Time: February 13, 2018, 2:00 – 3:00 pm ET

Marcia Friedman:
Good afternoon. My name is Marcy Friedman and I’m representing the Clinician Outreach and Communication Activity, COCA, with the Emergency Risk Communication Branch at the Centers for Disease Control and Prevention. I’d like to welcome you to today’s COCA Call, Don’t Overlook Assessing Environmental Exposures during a Disaster in Every Day.

You may participate in today’s presentation via the webinar or you may download the slides if you are unable to access the webinar. The PowerPoint slide and the webinar link can be found on our COCA webpage at Free continuing education is offered for this COCA call. Instructions on how to earn continuing education will be provided at the end of the call.

In compliance with continuing education requirements, CDC, our planners, our presenters, and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Planners have reviewed content to ensure there is no bias. Content will not include any discussion of the unlabeled use of a product or a product under investigational use. CDC did not accept any commercial support for this continuing educational activity.

After the speakers have presented, you will have the opportunity to ask the presenters questions. You may submit questions at any time through the webinar system by clicking the Q and A button at the bottom of your screen and then typing in your question via the webinar system. For those who have media questions, please contact CDC Media Relations at 404-639-3286 or email If you are a patient please refer all your questions to your healthcare provider.

At the conclusion of this session the participants will be able to accomplish the following: Identify why taking an environmental exposure history is a critical consideration during a clinical intake, during a disaster or disaster recovery situation. List the rationale for taking an exposure history as part of a clinical assessment. Describe how to access the pediatric environmental health specialty units or PEHSU resources. And describe, correction, those are the three objectives for the call.

Today’s first presenter, we have Dr. Diane Hindman. Dr. Hindman is a board-certified pediatrician and a medical toxicology fellow with the Agency for Toxic Substances and Disease Registry. Our second presenter is Dr. Marya Zlatnik. Dr. Zlatnik is a Professor of Obstetrics, Gynecology, and Reproductive Services at the University of California San Francisco and she’s a mental and fetal health medicine specialist. She’s also the Associate Director for Maternal Fetal Health and Environment Program for the UCSF Pediatric and Environmental Health Specialty Unit, PEHSU, and a member of UCSF’s program in reproductive health and environment. Our third presenter is Dr. Perri Sheffield. Dr. Sheffield is an Assistant Professor at the Icahn School of Medicine and she’s the Deputy Directory of the Region Two Pediatric and Environmental Health Specialty Unit. Our final presenter today is going to be Dr. Amanda Kadoor, who we thank for presenting rather last minute on behalf of Brian Tensa, who is ill today. And Dr. Kadoor is a Behavioral Scientist in the Agency for Toxic Substances and Disease Registries division of Toxicology and Human Health Services, correction, Sciences. At this time, Dr. Hindman, please go ahead.

Diane Hindman:
Thank you, Marcy, and welcome to our listeners. Today we’re going to discuss the importance of assessing environmental exposures during a disaster and every day. Children, next slide please. Children under the age of 18 make up about 25% of the U.S. population but we often think of them as the future of our country. Importantly, they have different physiologic, behavioral, developmental, social, and mental health needs than adults. For example, young children exhibit hand to mouth behaviors and their shorter stature often puts them closer to the ground where toxic substances can concentrate. Additionally, they depend on adults to keep them safe.

As such, children are disproportionally vulnerable to environmental exposures in disasters and every day, differences that are often unrecognized and overlooked by professionals, policy makers, and the public in general. Common environmental exposures that can impact children both in the U.S. and abroad include air and water pollution, secondhand smoke, toxic industrial chemicals, pesticides, heavy metals, hazardous wastes and climate change. Next slide please.

In the most recent Global Assessment of the Burden of Disease from Environmental Risks by the World Health Organization, 22% of all death and disability in 2012 was attributable to the environment. The report also estimates that in children under the age of 5, up to 26% of all deaths could be prevented if environmental risks were removed. Beyond mortality, there are also morbidities associated with environmental exposures.

Consider pesticide exposure in pregnant women as an example. Studies have shown a 7-point reduction in IQ from moderate prenatal pesticide exposures. The financial impact of lost IQ points has been estimated at a loss of lifetime earnings of 2.39% for every 1 point IQ loss. For pesticide exposures, this would be almost 17% if we utilized this calculation; certainly not an insignificant effect. In addition to the morbidity and mortality associated with childhood environmental exposures, the annual costs are astounding. Prüss-Üstün in 2008 analyzed this financial burden in the U.S. and estimated it to be $76.6 billion annually or 3.5% of the U.S. healthcare costs. This was up from 54.9 billion in 2002. These numbers considered only every day exposures and not any particular disasters. Next slide please.

We know that not everyone is an environmental expert nor have they had training in environmental health or toxicology; however, in most communities as healthcare and public health providers, you are ideally positioned to identify and help address environmental issues whether they are every day exposures, currently evolving disasters, or the aftermath. Your local proximity and established relationships with patients and others in your community gives you an edge that other outsiders may not have. Whether during acute care or health supervision visits, taking a patient’s environmental history can be instrumental in identifying worrisome and toxic exposures.

The trust patients and parents have in you, establishes the solid foundation upon which anticipatory guidance and associated changes can occur. You know about your community, its socioeconomic challenges, industries, climate, and history. This will enhance not only your knowledge of potential exposure risks but also your ability to engage in local activities that can alter such risks. Many communities and organizations are also thinking of emergency and disaster preparedness in light of recently problems and disasters that have impacted our country. You can start with your own practice in developing environmentally-friendly practices as well as disaster planning. But I am not an expert in environmental health so where do I turn for assistance and answers, you say. That’s where the PEHSUs come to your assistance. Next slide please. Next slide please.

When encountering a patient who may have toxic environmental exposures in your community, there is a regionally based national network of experts available to help you. The PEHSUs. These units are dedicated to increasing knowledge about environmental medicine among primary care providers and helping to protect children from environmental harm at all ages, from conception through childhood. The PEHSU network is comprised of experts in pediatrics, allergy and immunology, neurodevelopment, toxicology, occupational and environmental medicine, nursing, maternofetal medicine and other specialized areas. Key responsibilities that they fulfill include those that are listed on this, on the previous slide. This network service is available without a subscription and it’s free of charge.

The PEHSUs are located in academic medical centers in 12 regional locations to ensure that expert advice on local environmental exposures your patients may be facing can be provided to meet your needs. In addition to the 10 regions shown on this map, there are also PEHSUs that provide environmental health support in Canada and Mexico. The report by Woolf et al in 2016 shows the value that PEHSUs have delivered to healthcare providers, the general public, and public health officials. They delivered advice to more than 700,000 people, more than half of which was provided to healthcare and public health professionals in the first 15 years of their existence. Next slide.

The final slide just gives you a number of references that may be of interest to you in further support of your interest in environmental exposures and the associated risks. Thank you for attending our presentation. I would like to turn the presentation now over to Dr. Marya Zlatnik.

Marya Zlatnik:
Next slide please. Thank you Dr. Hindman and good day everyone. I’m going to present a case where I became involved where a pregnant woman was exposed to potential wildfire smoke. Next slide.

So this was a healthy woman, 29 years old. She had three prior full-term pregnancies and a history of gestational diabetes, a history of childhood asthma but was generally a healthy person. Next slide. And I met her at 31 weeks of pregnancy when she was transferred from a hospital in Santa Rosa, which is where some of the fires were last fall in California, after a preterm premature rupture of the membranes, again at 31 weeks of gestation. Next slide. And these wildfires, which I’m sure most of you heard about in the news, were quite significant and they prompted evacuation of some local hospitals but my patient was without any direct smoke exposure. When she arrived at our hospital she had no respiratory symptoms at all, her vital signs were normal, she had a normal oxygen saturation. But she did express concern about her husband as well as her house, which were in the evacuation area. Next slide.

So why would wildfire smoke be a concern in pregnancy? And I think there are a few layers to the concerns about wildfire smoke. As an obstetrician, certainly immediately what I think about is the physiology of pregnancy and that includes changes in respiratory and cardiovascular mechanics to provide oxygen and nutrition to the developing fetus. So this involves an increase in minute ventilation, so more ventilation happening each, each minute and higher metabolic needs. And this renders pregnant women more susceptible to a variety of complications including hypoxia and respiratory diseases such as the flu. This is quite well established. And we also know that fetal growth and wellbeing are dependent on maternal respiratory function. So if a woman has respiratory embarrassment, this is going to impact her fetus in the womb. Next slide please.

So in addition to these sort of basic concerns of how is the woman doing and is she able to breathe okay, we also know from some epidemiologic studies that wildfire smoke may cause other pregnancy complications. We don’t yet have data from the most recent set of wildfires, both in Northern and Southern California, to tell us whether they’ve impacted pregnant women but we do have data from the significant wildfires that were over a decade ago in Southern California and in these fires there was quite a bit of forest that was burned and the direction of the wind flow was such that the smoke blew over populated areas in Southern California and so these researchers used the opportunity to look for an effect on birth weight and they found that women who were in the second and third trimesters of pregnancy during this period of heavy smoke exposure had smaller babies.

There are also, next slide please. There’s not enough time today to go over all the research that looks at air pollution in various forms and the effect on pregnancy but certainly a number of studies have shown similar impacts of air pollution in general, including particulate matter or other components of air pollution, and decreased birth weight as well as other pregnancy outcomes like preterm birth. So even though we don’t know specifically from this wildfire whether it’s going to impact the women of California who are pregnant, we can hypothesize that there would be an increased risk. Next slide please.

So when we see a pregnant woman with smoke exposure from something like a wildfire or from some other disaster. Obviously, initially the kind of medical care we’re going to provide is the care that everybody gets. So the ABCs and ICU type care, if that is needed. For pregnant women, obviously, we need to tend to her pregnancy needs either by an obstetrician or a maternofetal medicine specialist and then if there are specific suspected exposures or concerns about exposures such as carbon monoxide, heavy metals, or flame retardants, then we need an expert in those things and traditionally OB/GYNs in the United States have not had a lot of education on these types of exposures so oftentimes this will require consulting somebody who has toxicology knowledge or occupational health knowledge or a PEHSU expert. In addition, many times we, especially in a situation of a widespread disaster, we hear from women who are not themselves ill but they’ve had exposure. So in the case of the wildfires, we’ve heard from women who were miles away from the fires but could smell smoke in the air and were worried about their exposures and what the impacts would have on their pregnancies. And this is the situation where the PEHSU is happy to provide consultation but we also have available on our website fact sheets about a number of environmental exposures and disasters that can be very useful in providing guidance to providers and to patients in these sorts of situations. Next slide please.

So this is an example from our Western States PEHSU of some guidance for both children and it also applies to pregnancy as far as what people can and should do during times of wildfire smoke exposure. Next slide please.

So in summary, it’s very important to take an exposure history as part of a clinical assessment, and particularly in a situation where there may be exposures after a disaster. We know that pregnant women are susceptible to smoke of various varieties and air pollution is a risk factor for adverse outcomes in pregnancy. The PEHSU network is a great resource both for consultation as well as for fact sheets and other information. Thank you very much for your attention. I’d like to turn the presentation over to Dr. Perri Sheffield.

Perri Sheffield:
Next slide please. Hi, this is Perri Sheffield. As we said, I work with the Federal Region 2 PEHSU and we cover New York, New Jersey, Puerto Rico and the Virgin Islands, that I’ll be focusing on today. Next slide please.

Puerto Rico and the U.S. Virgin Islands are part of the United States. The inhabitants are Americans, American citizens with respectively over 3 million and about 150,000 living on these different parts of the Caribbean. The two hurricanes, Irma and Maria, in September of 2017 caused worse damage than most people living there can remember in their lifetime of any storm causing. As of January 2018, last month, a third of those in Puerto Rico are still without power. Our Region 2 PEHSU based at Mt. Sinai in New York City, as I said, covers this federal region and has been working with partners in these two locales for the last decade. So we are building on these partnerships to help support the islands during the response and recovery. The photos in this talk were all taken when our PEHSU traveled to the islands in December. Next slide please.

So using an analogy from this damaged signage at the Luis Munoz International Airport in San Juan, healthcare providers also lack direction in managing and preventing environmental health exposures. This is the case at baseline nationwide as providers are chronically under trained in this area and this situation is worsened during acute disasters.

I’m seeing that there’s some notes about the volumes. I’ll try to speak a bit louder.

So despite under training, healthcare providers are frontline and they often do see many of these issues and manage them on a day-to-day basis but are ill-equipped to bring about the systems change that are needed to address these problems. The PEHSU works to build healthcare provider capacity in environmental health on an ongoing basis and then we can also serve as an additional resource during crises, particularly where relationships already exist, as with the Region 2 PEHSU’s work in the Virgin Islands and Puerto Rico. Next slide please.

In, let’s see, three months post hurricanes in Puerto Rico, here a power pole was still hanging dangerously over the street near this town of Naguabo on the eastern coast of the island and physical safety hazards like this are environmental hazards but they really represent the tip of the iceberg. Also in this scene, but not as visible, I want you to think about water-damaged structures. This area was flooded, where people live and work, power generators that are running, if not continuously at least overnight as this area continues to be without electricity. They create noise and air pollution. There’s also the psychosocial and economic stress of disrupted routines, loss of livelihood, lack of schools. The entire island of Puerto Rico had an ongoing economic crisis that predated the hurricanes and was already faced with potential hundreds of school closings and so this compounded that problem. Also, in the area to the left among the palm trees in this picture, was previously full of beach side kiosks of vendors and now just wooden stubs remain where those are. So this is an area, while it seems like there’s maybe only one obvious problem in this picture, there’s many actually as you start to scratch the surface. Next slide please.

So this is a picture from St. Thomas in the Virgin Islands. We have a school nurse collaboration that addresses environmental health issues in schools and, in this picture, you see a second shift of students arriving midday at an elementary school. The two schools are now functioning in one building since multiple schools were destroyed. At baseline, environmental issues are often multifactorial and disasters, such as the hurricane, make these relationships more nuanced and complex. Next slide please.

So these are some pictures from inside that same school. Remember that this is one of the least affected facilities where children now have their shortened school day because of dual shifts. The shaded outdoor tables in the upper left are the makeshift cafeteria and waiting area during the student shift change as the gym and cafeteria in the lower left is not functional due to water damage. In the upper right and lower right we see water damaged sheetrock was removed, which is good, in some areas but that left openings and a view from the nurse’s clinic into the main office. Not pictured here but also present in this same school are areas like the library that are mold contaminated because of water damage. Also, standing water on the property contributes to insect and other pest problems.

So we have to consider all of these factors when we think about the environment, the school environment. And then we also need to think about that these children and many of the staff are going home to damaged housing where there is mold risk from water and moisture issues due to leaks and also lack of air conditioning and there’s also additional stressors. Family members often are having to be transported off island for anything beyond basic healthcare, at least initially, and so that creates additional stressors for the family. The PEHSU is working with the school nurse at this school to corroborate her environmental health concerns and elevate these issues through proper channels to make sure that they’re addressed as safely and as quickly as possible. Next slide please.

Additionally, a small but vibrant sustainable food movement exists on these islands, both in Puerto Rico and the Virgin Islands and local production, as you can imagine, was dramatically affected by the storms but communities are bouncing back. This picture is from a farming brigade in the mountains of Puerto Rico, Aibonito for those who are familiar with the island, where neighbors are helping each other rebuild using reclaimed materials actually from storm damaged other buildings. The family living on this property grows food for the local farmers market and residents of the area have been told that they should not expect restoration of power for at least two years. Our PEHSU team also works to find and support efforts such as these, ones that promote health and resilience, shining light on such important work by articulating the health benefits, connecting them to the healthcare community, and vice versa when the healthcare community is not aware about such efforts, and then linking them to additional resources as able are other roles that our PEHSU serves. Next slide please.

So with that all summarized, just emphasizing that there are over 3 million Americans in the Caribbean that were impacted by these 2017 hurricanes. The PEHSU is working with diverse partners to address these complicated environmental health issues that affect children and the take home for those of you who aren’t directly connected to this, this area and this region, is that there’s a PEHSU in every region and getting to know yours before disaster strikes can be very beneficial. You don’t have to go it alone. With that, I’ll pass the webinar back to the CDC for some sharing of resources, Dr. Amanda Kadoor.

Amanda Kadoor:
Thank you Dr. Next slide please.

Hi everyone, my name is Amanda Kadoor. I will take the doctor title; however, I’m a doctoral candidate so I will claim that. But I’m one of the team members in the environmental medicine branch. Brian Tensa is my team lead so I’ll be presenting on his behalf. I’m going to spend a few minutes discussing some of our educational resources geared towards health professionals that can be found at the Agency for Toxic Substances and Disease Registry or ATSDRs webpage. Please keep in mind that most of our materials I will mention includes free continuing education credits. Next slide please.

Our environmental medicine education materials can be found on our website at There you can find information for both health professionals and the general public as well as guidance from the Pediatric Environmental Health Specialty Units or PEHSUs. On the left hand side of the webpage our drop down menu section titles Resources for Health Professionals and Resources for the Public as well as sections for quick links and key resources. On the right hand side of the page you will see a spotlight section, which will cover most of the modern day information on environmental health.

Today we’re going to focus primarily on our health professionals links. Under the health resources, which is on the left hand side of the page, you’ll see an area of resources for health professionals and that links to several of our educational products such as our case studies in environmental medicine, our grand rounds in environmental medicine, patient education and care instruction sheets, PEHSUs, PFAS, Story of Health, our ALS emergency risk communication, pediatric environmental health toolkit and Surviving Stress for first responders. Next slide please.

As I previously stated, links to all of our materials are available free, that provides free continuing education credits. I’m sorry. So let us start off by looking at our Story of Health. The Story of Health is an online e-book that is told through the lives of fictional characters and their family. It focuses in on four main health scenarios such as Brett, which is a young boy with asthma; Amelia, a teenage girl with developmental disabilities; Stephen, a toddler recently diagnosed with leukemia; and a couple dealing with infertility.

Each fictional case features the latest scientific research about disease origin and helpful facts about disease prevention. Graphics and videos enhance each page. Links to a wide range of additional resources and hundreds of scientific papers enrich each story with information you can use today to promote health and prevent disease. Each story is available online for free continuing education. Story of Health was developed in collaboration with ATSDR, the Collaborative on Health and Environment, the Office of Environmental Health Hazard Assessment, California Environmental Protection Agency, the Science and Environmental Health Network, and the University of California San Francisco PEHSU. Next slide please.

The case studies in environmental medicine are a series of self-instructional modules designed to increase the primary care provider’s knowledge of hazardous substances in the environment and to aid in the evaluation of potentially exposed patients. Some of our case studies include taking exposure history, environmental triggers of asthma, lead, polychlorobiphenyls or PCBs, and carbon tetrachloride. Next slide please.

On this slide you can see a detailed list of the contents covered in our case studies, from symptoms to patient management with details from several case studies. These case studies can be used for continuing education or for a reference for health professionals. Next slide please.

The patient education and care instruction sheets were designed to complement the case studies in environmental medicine as well as the grand rounds packet. These job aids provide general information on various environmental medicine topics and give healthcare professionals quick, ready to use materials to aid in patient care and instruction. Patient education and care instruction sheets are available and downloadable online. The online learner can control the pace of the products through chapter organization and hyperlinks. Next slide please.

The grand rounds and environmental medicine webstream presentations are continued education, video webstream designed for primary healthcare providers and for other professionals who work in environmental health. In this asbestos slide, there is a discussion on what advice to give patients along with its rationale. Next slide please.

ATSDR Pediatric Environmental Health Toolkit Training Module is an excellent source of resources for primary care health professionals who work in pediatrics. The toolkit is an interactive web-based module and introduces users to the basics of environmental health and explains the purpose and best use of the toolkit. It offers healthcare professionals detailed examples about how to best deliver anticipatory guidance and a range of environmental health issues especially during well care visits. It contains case examples that explore the unique biological factors, exposes patterns that make children especially vulnerable to toxic chemicals. It offers free continual education. Next slide please.

The relocation strength fact sheet helps providers assist individuals and families dealing with stress following relocation due to a disaster. It focuses on the entire family from adolescence to the elderly.

Basic information about signs of stress as well as how to help those affected is provided. Surviving Stress for the First Responder is a video webstream course designed to help first responders and those they assist to be prepared for the stressors of 21st century disasters. It was developed in collaboration with the Environmental Protection Agency. These courses attempt to describe psychological stress, explain common causes of stress, describe the mental and physical health effects of excessive stress, describe the social, physical, and emotional causes of first responder stress, identify methods to cope with field related stress and identify strategies for assisting members of the public, which includes adults and children with disaster-related stress. Next slide please.

Child Development in Resilience and Environment is a recorded presentation that discusses the many complex interactions that affect health both positively and negatively. The presentation focused on how environmental exposures and social experiences, particularly during early life, can contribute to resilient outcomes. Specifically, it attempts to explain an ecological framework in regards to health and identify early life factors can affect adult health, explain critical time windows, explain how resilience can help mitigate negative early life factors, and discuss environmental justice and its interaction with vulnerable and resilience. It was developed in assistance with PEHSU as well as Dr. Vickie Leonard, Brian Tencza, Steve Burda, and Christine Zachek Next slide please.

As many of my fellow colleagues and presenters has explained, that we work with the PEHSU. PEHSU, which is funded by ATSDR, has launched a website for the public and healthcare practitioners to aid in the prevention of environmental exposures among children. This newly structured resource houses the PEHSU National Classroom, which allows healthcare professionals access to resources, webinars, and interactive online courses on a various topics relating to environmental health. Next slide please.

In summary, ATSDR offers a wealth of environmental medicine educational materials. When you have an opportunity, please visit our website at underscore professionals. As I previously stated, most of our products offer free continuing education credits. Thank you for your time and attention and I will now turn the presentation over to Marcy for the question and answer portion of this presentation. Thank you.

Marcia Friedman:
Thank you so much, Amanda. We really appreciate your stepping in for Dr. Tensa today, especially at the last minute. Thank you so much and also thank you to our other presenters.

We’re now going to move into our Q and A session of the call. Please remember you may submit any questions you may have through the webinar system by clicking the Q and A button at the bottom of your screen and then typing in your questions. If you have questions after the call you’re more than welcome to send them to, which is c-o-c-a at So our first question that came in through the webinar system is for Dr. Zlatnik and the question is what sorts of pregnancy related environmental exposure questions come to the PEHSUs?

Marya Zlatnik:
Thank you, Marcy. You know, there’s really a wide variety of questions that come through and certainly any time there is something like a disaster there are questions related to that or not necessarily a natural disaster, a manmade disaster like the situation with lead in Flint, a lot of those questions came through the PEHSU and many times when there is pediatric exposure, there may also be a maternal exposure at the same time. So if there’s a small child in the house who’s been exposed to something, there is a chance that in that household there might also be a pregnant mom and so sometimes that’s how these questions come up.

Outside of the disaster environment, I think some of the most common questions have to do with things like lead in the various different places that it can be found, whether it’s lead paint or lead in the water, or lead in cosmetics, or herbal medications. We also now, as marijuana use is becoming more common or legalized in various parts of the country, we’re seeing more questions about marijuana exposure in pregnancy. But we’re really happy to take any kinds of questions. You know, there are some rare exposures that we don’t necessarily know the answer to off the top of our head but we have a very robust network of experts around the country. So if I get a question and I don’t know the answer then I know, you know, who I can go to get an answer for that. Thank you.

Marcia Friedman:
And thank you so much. The next question is for Dr. Sheffield and that question is how could a clinician take advantage of their regional PEHSU resource in the aftermath of a disaster like the hurricanes presented?

Perri Sheffield:
Thank you, Marcy. That’s a great question. I think the first thing I would say is to get in touch early and often. All of the PEHSUs are doing a fair amount of outreach on their own but none of the PEHSUs, none of the regional PEHSUs reach comprehensively their entire region and so if you aren’t already familiar with the pediatricians or other medical personnel and experts who make up the PEHSU team for your region, look them up. Give them a call and introduce yourself and ask them sort of what are their specific initiatives.

But then specifically, post disaster, I think of the PEHSU in having two roles, one is if needed, to get evidence-based screening and management advice out, give that to the clinicians particularly if you’re calling with a specific concern about how to manage or whether or not you need to test for certain chemical exposure. But then the second would be the reverse. The healthcare providers are the frontline and so by reaching, getting in touch with your PEHSU can help amplify what you are seeing and the PEHSUs, by and large, have existing relationships with local, regional, and federal government agencies who often are tied directly to the recovery and response efforts and so by bringing those concerns to the PEHSUs they can help amplify that need and potentially direct resources to where they need to be going.

Marcia Friedman:
Thank you so much, Dr. Sheffield. Our next question is for any of the panelists to answer and that is when folks are using reclaimed materials are there any concerns or cautions regarding potential lead paint or asbestos on those materials?

Perri Sheffield:
This is Perri Sheffield again. I think maybe that question came when I highlighted the use of materials post hurricane being used in some of the farming activities and that’s a great question. Just asking the question is the first step. We want people to be asking questions like that. And yes, there are potential concerns when you use reclaimed materials. I thought about that on that very day when we were looking at that but I learned that those, in that case those reclaimed materials were coming from a new subdivision, which had been built since lead and asbestos were in common usage so I wasn’t concerned about those two exposures but it doesn’t mean that there might be others, and sometimes the plastics that are getting used raise concerns about potential leaching of chemicals. And so that’s something that you could take to a PEHSU and if your specific PEHSU didn’t have the expertise we have an entire network and we poll each other when we don’t have specific answers. But you should know that the PEHSUs have different expertise, meaning it’s not just clinicians, pediatricians with environmental health training, or other clinicians but, for example, at our regional PEHSU we have an industrial hygienist and we also have connections to, in our larger network, of material experts that we could pose those questions to.

Marcia Friedman:
Thank you, Dr. Sheffield. Okay, another question that has come in is do the PEHSUs ever work with sheltering/the Red Cross during disasters?

Perri Sheffield:
This is Perri Sheffield again. I’m not aware of any specific collaborations and that doesn’t mean that it hasn’t happened, and that’s a great idea. One of, after Super Storm Sandy a few years ago in the New York/New Jersey area we were specifically asked to think about childcare centers because that was recognized as a major gap in terms of just making sure they were being evaluated with a child-focused health perspective when they were being brought back online and so you could say the same thing about shelters and making sure that those are safe environments for children or pregnant women, for example. That’s a great question, great idea.

Marcia Friedman:
Thanks, Dr. Sheffield. Looks like we have one final question that has come in through the webinar system and that is, I have a 4-year-old patient whose blood levels, correction, whose blood lead levels are borderline. I’m not sure when I should consider chelation or should I call locally to have the patient evaluated.

Diane Hindman:
This is Dr. Hindman. I think at the point that you have someone who, or a child who has borderline lead levels, you could certainly contact a whole number of hosts but my recommendation would be to speak first to your local PEHSU. They can help to provide guidance and, as we’ve mentioned, they do work with many other subspecialists who can provide the additional expertise that they may not, in fact, have in a particular PEHSU. This is just one of many dilemmas that many toxicologists and many pediatricians face when dealing with children who do have elevated lead levels. Dr. Sheffield, perhaps you may have some additional insight or Dr. Zlatnik based on your involvement directly in the PEHSUs but that would be my perspective as a toxicologist and a pediatrician.

Marya Zlatnik:
This is Marya Zlatnik. I agree that that’s a great place to start because they, I mean, depending on where you’re located geographically compared to where the PEHSU is, this may be the sort of thing that it can be a clinician to clinician consult over the phone and the patient may not need to travel if it’s, you know, straight forward, it’s just doing some blood work and monitoring. On the other hand, if it is a situation that’s going to lead to chelation or something more significant, than the PEHSU can provide a referral to what, you know, whatever makes the most sense geographically.

Marcia Friedman:
Okay, thank you both. All right. looks like we are finished with our Q and A session. On behalf of COCA, I would like to thank everyone for joining us today with a special thank you going out to our presenters, Dr. Hindman, Dr. Zlatnik, Dr. Sheffield, and Amanda Kadoor. Thank you, Amanda, again for stepping in for Brian this afternoon.

The recording of this call and the transcript will be posted within the next few days to the COCA website at All continuing education for COCA calls are issued online through TCE Online, the CDC training and continuing education online system at Those who participated in today’s COCA call and would like to receive continuing education should complete the online evaluation by March 15th of 2018 and use the course code wc2922. Those who will review the call on demand and would like to receive continuing education should complete the online evaluation between March 15th, 2018 and March 15th of 2020 using course code wd2922.

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Page last reviewed: October 5, 2018