PRINCIPLES AND INVESTIGATION OF

ENVIRONMENTAL FACTORS IN DISEASE

AND ENVIRONMENTAL DISEASES

Dr. Kazi Shihab Uddin

MBBS; MRCP (UK)
Associate Professor & HOD
Department of Internal Medicine
 Health emerges from a highly complex interaction between

factors intrinsic to the patient and his or her environment.

 Many factors within the environment influence health, including

aspects of the physical environment, biological environment

(bacteria, viruses), built environment and social environment,
but these also encompass more distant influences such as the
global ecosystem.
Hierarchy of systems that influence population health
 Investigations in environmental health

 Incidence and prevalence

 Variability by time, person

and place
 Measuring risk

 Establishing cause and

effect
ENVIRONMENTAL DISEASES
 Alcohol
 The World Health Organization (WHO) estimates that the harmful

use of alcohol results in the death of 2.5 million people annually.

 Most likely explanation is that the environment changed. The price of

alcohol fell in real terms and availability increased (more supermarkets

sold alcohol and the opening times of public houses were extended).
 Also, the culture changed in a way that fostered higher levels of

consumption and more binge drinking. These changes have caused a

trebling of male and a doubling of female deaths due to alcohol.
 Smoking
 Smoking tobacco dramatically increases the risk of developing many

diseases. It is responsible for a substantial majority of cases of lung

cancer and chronic obstructive pulmonary disease, and most smokers
die either from respiratory disease or ischemic heart disease.
 Smoking also causes cancers of the upper respiratory and

gastrointestinal tracts, pancreas, bladder and kidney, and increases

risks of peripheral vascular disease, stroke and peptic ulceration.
 Maternal smoking is an important cause of fetal growth retardation.

Moreover, there is increasing evidence that passive (or ‘secondhand’)

smoking has adverse effects on cardiovascular and respiratory health.
 Obesity
 Obesity is a condition characterised by an excess of body fat. In its simplest

terms, obesity can be considered to result from an imbalance between the

amount of energy consumed in the diet and the amount of energy expended
through exercise and bodily functions. People who are obese are more likely
to develop a range of chronic conditions.
 The best way, therefore, to understand the current obesity epidemic is to

consider humans as ‘obesogenic organisms’ who, for the first time in their
history, fit themselves in an obesogenic environment – that is, one where
people’s circumstances encourage to eat more and exercise less.
 This includes the availability of cheap and heavily marketed energy­rich

foods, the increase in labour­saving devices (e.g. lifts and remote controls)
and the increase in passive transport (cars as opposed to walking, cycling).
Poverty and affluence
 Extremes of temperature
 Body heat is generated by basal metabolic activity and muscle movement,

and lost by conduction, convection, evaporation and radiation.

 Body temperature is controlled in the hypothalamus, which is directly

sensitive to changes in core temperature and indirectly responds to

temperature­sensitive neurons in the skin.
 In a cold environment, protective mechanisms include cutaneous

vasoconstriction and shivering; however, any muscle activity that involves

movement may promote heat loss by increasing convective loss from the
skin, and respiratory heat loss by stimulating ventilation.
 In a hot environment, sweating is the main mechanism for increasing heat

loss. This occurs when temperature rises above 32.5°C or during exercise.
 Hypothermia
 Hypothermia exists when the body’s normal thermal regulatory

mechanisms are unable to maintain heat in a cold environment and core

temperature falls below 35°C
 Whilst infants are susceptible to hypothermia because of their poor

thermoregulation and high body surface area to weight ratio, it is the

elderly who are at highest risk.
 Hypothermia also occurs in healthy individuals whose thermoregulatory

mechanisms are intact but insufficient to cope with the intensity of the
thermal stress. Typical examples include immersion in cold water, when
core temperature may fall rapidly (acute hypothermia), exposure to
extreme climates such as during hill walking (subacute hypothermia), and
slow onset hypothermia, as develops in an immobilised older individuals.
 Investigations- Blood gases, a full blood count, electrolytes, CXR and ECG

are all essential investigations. Haemoconcentration and metabolic

acidosis are common, and the ECG may show characteristic J waves, which
occur at the junction of the QRS complex and the ST segment, Cardiac
dysrhythmias, including ventricular fibrillation, may occur.
 Management

 Following resuscitation, the objectives of management are to rewarm

the patient in a controlled manner while treating associated hypoxia (by

oxygenation and ventilation ), fluid and electrolyte disturbance, and
cardiovascular abnormalities, particularly dysrhythmias.
 In mild cases, slow rewarming @1-2 Celsius/hour.

 In severe cases, >2 Celsius/hour

 May need ICU admission and mechanical ventilation.

 Cold injury
 Freezing cold injury (frostbite)- This represents the direct freezing of body

tissues and usually affects the extremities: in particular, the fingers, toes, ears

and face. Risk factors - smoking, peripheral vascular disease, dehydration and

alcohol consumption. The tissues may become anaesthetised before freezing

and the injury often goes unrecognised at fist. Frostbitten tissue is initially

pale and doughy and insensitive to pain. Once frozen, the tissue is hard.

 Rewarming should not occur until it can be achieved rapidly in a water bath.

Give oxygen and aspirin 300 mg as soon as possible. Frostbitten extremities

should be rewarmed in warm water at 37–39°C, with antiseptic added.

 Adequate analgesia is necessary, as rewarming is very painful. Vasodilators

such as pentoxifylline have been shown to improve tissue survival.

 Non-freezing cold injury (trench or immersion foot)-This results from

prolonged exposure to cold, damp conditions. The limb (usually the foot)
appears cold, ischaemic and numb, but there is no freezing of the tissue. On
rewarming, the limb appears mottled and thereafter becomes hyperaemic,
swollen and painful. Recovery may take many months, during which there
may be chronic pain and sensitivity to cold. Gradual rewarming is associated
with less pain than rapid rewarming. The pain and associated paraesthesia
are difficult to control and may require amitriptyline .
 Chilblains- Chilblains are tender, red or purplish skin lesions that occur in

the cold and wet. They are often seen in horse riders, cyclists and swimmers,
and are more common in women than men. They are short­lived, and
although painful, not usually serious
 Heat related illness (heat exhaustion,
heat stroke)
 Heat cramps- These painful muscle contractions occur following vigorous

exercise and profuse sweating in hot weather. There is no elevation of core

temperature. The mechanism is considered to be extracellular sodium
depletion as a result of persistent sweating. Symptoms usually respond
rapidly to rehydration with ORS or I/V saline.
 Heat syncope- This is similar to a vasovagal faint and is related to peripheral

vasodilatation in hot weather.

 Heat exhaustion- Heat exhaustion occurs with prolonged exertion in hot and

humid weather, profuse sweating and inadequate salt and water replacement. There
is an elevation in core (rectal) temperature to between 37°C and 40°C, Blood
analyses may show evidence of dehydration with mild elevation of the blood urea,
sodium and haematocrit. Treatment involves removal of the patient from the heat,
and active cooling using tepid sprays and fanning (strip–spray–fan). Fluid losses are
replaced with either oral rehydration mixtures or intravenous isotonic saline.
 Heat stroke- when the core body temperature is >40°C, is a life threatening

condition. The symptoms of heat exhaustion progress to headache, nausea and

vomiting. Neurological manifestations as coarse muscle tremor and confusion,
aggression or loss of consciousness. The patient’s skin feels very hot, and sweating is
absent due to failure of thermoregulatory mechanisms. Complications include
hypovolaemic shock, lactic acidosis, disseminated intravascular coagulation,
rhabdomyolysis, hepatic and renal failure, and pulmonary and cerebral oedema.
 The patient should be resuscitated with rapid cooling by spraying with

water, fanning and ice packs in the axillae and groins. Cold crystalloid I/V
fluids are given but solutions containing potassium should be avoided.
 Appropriate monitoring of fluid balance, including central venous pressure,

is important. Investigations for complications include routine haematology

and biochemistry, coagulation screen, hepatic transaminases, creatine
kinase and chest X­ray. Once emergency treatment is established, heat
stroke patients are best managed in intensive care.
 With appropriate treatment, recovery from heat stroke can be rapid (within

1–2 hours) but patients who have had core temperatures higher than 40°C
should be monitored carefully for later onset of rhabdomyolysis, renal
damage and other complications before discharge from hospital.
Illnesses at high altitude
Acute mountain sickness

High-altitude cerebral oedema

High-altitude pulmonary oedema

Chronic mountain sickness

(Monge’s disease)
High-altitude retinal haemorrhage

Venous thrombosis

Refractory cough
 Drowning and near-drowning
 Drowning is defined as death due to asphyxiation following immersion in a

fluid, near­drowning is defined as survival longer than 24 hours after

suffocation by immersion.
 Drowning remains a common cause of accidental death throughout the

world and is particularly common in young children. In about 10% of cases,

no water enters the lungs and death follows intense laryngospasm.
 Prolonged immersion in cold water, with or without water inhalation, results

in a rapid fall in core body temperature and hypothermia. Those rescued

alive (near­drowning) are often unconscious and not breathing.
 Hypoxaemia and metabolic acidosis are inevitable features. Acute lung

injury usually resolves rapidly over 48–72 hours, unless infection occurs.
 Complications include dehydration, hypotension, haemoptysis,

rhabdomyolysis, renal failure and cardiac dysrhythmias. A small number of

patients, mainly the more severely ill, progress to develop the acute
respiratory distress syndrome
 Management- Initial management requires cardiopulmonary resuscitation

with administration of oxygen and maintenance of the circulation. It is

important to clear the airway of foreign bodies and protect the cervical spine.
 Continuous positive airways pressure (CPAP) should be considered for

spontaneously breathing patients with oxygen saturations below 94%.

 Observation is required for a minimum of 24 hours. Prophylactic

antibiotics are only required if exposure was to contaminated water.

 Atmospheric pollution
 Emissions from industry, power plants and motor vehicles of sulphur oxides,

nitrogen oxides, respirable particles and metals are severely polluting cities
and towns in Asia, Africa, Latin America and Eastern Europe.
 Increased death rates from respiratory and cardiovascular disease occur in

vulnerable adults, such as those with established respiratory disease and the
elderly, while children experience an increase in bronchitic symptoms.
 Developing countries also suffer high rates of respiratory disease as a result of

indoor pollution caused mainly by heating and cooking combustion.

 Carbon dioxide and global warming
 Climate change is arguably the world’s most important environmental health

issue. A combination of increased production of carbon dioxide and habitat

destruction, seems to be the main cause.
 The temperature of the globe is rising, climate is being affected, and if the

trend continues, sea levels will rise and rainfall patterns will be altered so that
both droughts and fl0ods will become more common. These have already
claimed millions of lives during the past 20 years and have adversely affected
the lives of many more.
 The economic costs of property damage and the impact on agriculture, food

supplies and prosperity have also been substantial. The health impacts of
global warming will also include changes in the geographical range of some
vector­borne infectious diseases.
Radiation exposure

Diving related illness- decompression illness and

barotrauma
Air travel injury- hypoxia, deep venous thrombosis,

pneumothorax, high altitude pulmonary oedema.

Thank you all