Assigment .Apa seven . All instructions attached.

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Case Study 2: Mercury Poisoning in a Hispanic Community

Session Overview

Instructions For the purposes of this exercise, you will be asked to work in groups to participate in a mercury poisoning investigation that is based on a true scenario. Information regarding the scenario will be provided to you in parts, each of which will be followed by related discussion questions. Choose one group member to read each segment of information aloud to the rest of the group. After receiving the information, work as a team to formulate answers to each discussion question.

Intended Audience All public health, medical, veterinary, pharmacy, emergency management, hospital, and other professionals interested in public health preparedness and field epidemiology. Time Required (estimated) 90 minutes Learning Objectives

 List common sources of mercury exposure  Identify appropriate control measures to prevent additional cases of mercury

poisoning  Develop risk communication messages for the public

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Case Study 2: Mercury Poisoning in a Hispanic Community

Pre-Test

1. Which of the following are questions to be asked when conducting an interview with a patient to assess his or her potential exposure to mercury?

a. Do you take any vitamins, dietary supplements, alternative medicines or herbal remedies?

b. Do you have any tattoos? c. Are you involved in the manufacturing of thermometers, barometers,

thermostats, blood pressure machines, chlorine, batteries, fluorescent lights, or jewelry?

d. What types of fish do you eat? e. All of the above f. A, C, D only

2. True or False: Health department employees are authorized to confiscate products with known health risks and prohibit a store from selling them.

3. Which of the following state and/or federal agencies should be notified if mercury has been found in a product?

a. State health department b. FDA c. EPA d. Office of the Attorney General e. All of the above f. A and B only

4. True or False: Pilot-testing media messages with the intended audience can help to ensure the cultural appropriateness of your message.

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Case Study 2: Mercury Poisoning in a Hispanic Community

Student Guide

Situation

You work in the environmental health unit of a local health department. This morning, you receive a call from LabTech, a private laboratory that conducts many laboratory tests for healthcare providers in your county. The lab is calling to report a mercury level of 90μg/L (micrograms per liter) in the urine of a 31-year-old woman. A mercury level of 10μg/L or above in urine or blood is considered to be elevated.

1. What information would you want from the laboratory that conducted the test?

Update 1

Before proceeding further, you conduct some basic research about mercury, including a search for journal articles about mercury exposure. Below is a brief summary of your findings. (Table 1) Mercury is a toxic metal that can cause damage to the nervous system and kidneys, and is especially dangerous for fetuses, infants, and young children. Mercury testing is not routine, and is usually conducted only when mercury exposure has been suspected. The forms of mercury and some common types of exposure are listed below. In general, high levels of mercury in the urine indicate inorganic mercury exposure (from occupational or other exposure, while high levels in the blood indicate organic mercury exposure from fish and shellfish consumption.

Table 1. Summary of Research Findings

Form Exposures Found In

Inorganic (including metallic)

 Accidental spills (e.g., broken thermometers)  Inhalation from combustion of mercury-

containing fuels or waste  Occupational inhalation for workers  Dental amalgam (for fillings)  Creams and ointments used for antiseptic or

skin-lightening purposes  Use of elemental mercury in religious rituals and

ceremonies

Urine Whole blood (only for recent exposures)

Organic (methylmercury)

 Fish and shellfish consumption Whole blood Scalp hair (uncommon)

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2. Based on the information provided, do you think the woman was exposed to organic or inorganic mercury? How does this information affect your assessment of likely source(s) of exposure? What additional test(s) could confirm the type of mercury?

3. What is the possibility that other people in the patient’s household or workplace may

also be exposed to mercury?

Update 2 According to LabTech, the urine testing was ordered by a local physician, Dr. Lockhart. You contact Dr. Lockhart, who explains that she requested the test because her patient, Maria Rivera, had been experiencing slight tremors for about a year. Dr. Lockhart had ruled out other causes and decided to test for heavy metal exposure as a last effort to determine the cause of the tremors. A urine test confirmed high levels of mercury. Dr. Lockhart is very concerned about finding the source of Maria’s mercury exposure and provides you with Maria’s phone number so you can contact Maria directly. You decide to conduct a telephone interview with Maria. Dr. Lockhart also agrees to conduct a blood test for mercury to confirm that the exposure is inorganic.

4. Group Brainstorm: Have one member of the group write ideas on the

flip chart. What questions will you ask Maria to assess her potential exposures to mercury?

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Update 3 You call Maria and learn that she primarily speaks Spanish, so you ask one of your bilingual colleagues to conduct the interview in Spanish. Maria is somewhat reluctant to participate in an interview over the phone, but your colleague is able to get some limited information (see below).  Age: 31  Health: good, no chronic health problems or current symptoms (other than tremors)

reported  Fish consumption: 2 meals weekly, includes albacore tuna and fresh tuna but no

swordfish or shark  Accidental spills: none recalled  Occupation: floral arranging  Country of origin: Mexico  Family: husband and two children (ages 3 and 5)

Lab testing results show a blood mercury level of 15μg/L, which is slightly elevated, but within the expected range of 2-20μg/L found in people who consume fish.

5. How does this affect your hypothesis about Maria’s probable source of mercury

exposure? 6. What are the next steps you would take to narrow down the source of Maria’s

mercury exposure?

Update 4 You decide to conduct a home investigation to identify the specific source of Maria’s exposure. You and a colleague take samples of the paint, air, and soil around her home. You ask Maria if she uses herbal remedies or skin creams. She shows you a bottle of herbal supplements, and a cream that she uses every night for skin lightening. With her permission, you take both bottles to the laboratory, where testing reveals the skin-lightening cream contains mercury at 6,100 parts per million, far higher than the 1 ppm threshold allowed by the Food and Drug Administration for cosmetic products (21 CFR 700.13). You contact Maria to share this information, advise her not to use the cream, and find out where she bought the cream. You realize that since mercury testing is not conducted routinely, there could be many other people in your community using the skin cream.

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7. What strategies will you use to determine if there are additional cases of mercury poisoning in Maria’s family or the community?

Update 5 Maria tells you that she bought the cream at a local Hispanic beauty supply store. You visit the store, and find several bottles of the same skin-lightening cream on the shelf. You also notice that there are two other types of skin-lightening creams, one with mercury salt listed as an ingredient, and the other without a list of ingredients.

8. You would like to ensure that the beauty supply store stops selling these skin creams.

As a health department employee, do you have the authority to confiscate products with known health risks and prohibit the store from selling them?

9. Which state and/or federal agencies should you notify about this situation?

Update 6 Your health director decides to issue an order prohibiting the sale of any brand of skin- lightening cream containing mercury or mercury salts. This order will be distributed to all stores in the county that sell cosmetic products. However, since many people may already have skin creams at home, you would like to craft a message to the public warning them about the dangers of using such creams.

10. Group Activity: Work together to create a short message about the danger of

mercury exposure from skin-lightening creams. When developing your message, consider your intended audience and method of delivery (e.g., television, radio, print or social media).

11. How can you ensure that your message is culturally appropriate for your intended

audience? 12. Are you aware of groups in your own community that may be exposed to mercury

through occupational exposure, use of mercury in products or rituals, or other sources?

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Conclusion You disseminate an advisory about the skin creams in both English and Spanish to the general public and post warnings about the skin creams in beauty-supply stores throughout the area. Your environmental health unit conducts inspections of local stores to ensure that the skin-lightening creams have been removed from the shelves. You also begin to work with your local Hispanic coalition to develop and pilot test health messages that are specifically focused on Spanish-speaking Latino populations. Meanwhile, area laboratories report an increase in the number of mercury tests conducted, which you interpret as an indication of increased awareness of mercury poisoning among healthcare providers or the general public.

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References

Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological profile for Mercury. Atlanta, Ga: U.S. Department of Health and Human Services, Public Health Service; 1999. Available at: http://www.atsdr.cdc.gov/toxprofiles/tp.asp?id=115&tid=24. Accessed April 6, 2016. Centers for Disease Control and Prevention. Mercury (Inorganic) Case Definition. 2013. Available at http://emergency.cdc.gov/agent/mercury/mercinorgcasedef.asp. Accessed April 6, 2016. Chan TY. Inorganic mercury poisoning associated with skin lightening cosmetic products. Clin Toxicol (Phila).2011;49(10):886-91. Use of mercury compounds in cosmetics including use as skinbleaching agents in cosmetic preparations also regarded as drugs. Code of Federal Regulations, Title 21, Pt 700.13. Revised April 1, 2015. Available at: http://www.ecfr.gov/cgi-bin/text- idx?SID=9f9565267f4d3fb9397fda43aa0a254b&mc=true&node=se21.7.700_113&rgn= div8. Accessed April 6, 2016. Washam C. Beastly beauty products: exposure to inorganic mercury in skin-lightening creams. Environ Health Perspect. 2011;119(2):A80-A81.