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Toxic chemical exposures associated with food premises Catherine Keshishian Public Health England - Centre for Radiation, Chemical and Environmental Hazards Overview • About the PHE Centre for Radiation, Chemical and Environmental Hazards • Acute incident response • Chronic enquiries • Other work • Chemical poisoning associated with food premises: • Carbon monoxide poisoning incidents • Other toxic gases • Heavy metals 2 About the PHE Centre for Radiation, Chemical and Environmental Hazards 3 Public Health England • Formed on 1 April 2013 under the Health and Social Care act 2012 • Brings together public health functions, including Health Protection Agency • Category 1 responders under Civil Contingencies Act “To protect and improve the nation’s health and to address inequalities, working with national and local government, the NHS, industry, academia, the public and the voluntary and community sector.” 4 The three domains of public health Health Improvement Health Protection Healthcare Public Health – Inequalities – Infectious diseases – Clinical effectiveness – Education – Chemicals and poisons – Efficiency – Housing – Radiation – Service planning – Employment – – Audit and evaluation – Family/community Environmental health hazards – Clinical governance – Lifestyles – Equity – Surveillance and monitoring of specific diseases and risk factors 5 – Emergency response * Definitions from the Faculty of Public Health, 2013 CRCE responsibilities - Acute chemical incident response - Chronic chemical incident response - Emergency planning eg COMAH - Environmental permitting & planning - Surveillance and research - Training 6 Incident response 7 Role during an acute incident Advice to first line responders / public health: • Health effects of chemical and environmental hazards • Toxicology and decontamination • Environmental sampling, modelling and analysis Actions: • Undertake public health risk assessment • Liaise with other agencies, including multiagency groups • Scientific and Technical Advice Cell • Air Quality Cell • Communications 8 Public health risk assessment Exposure assessment Risk characterisation Risk = Hazard x Exposure What is the risk associated with that exposure? Risk communication Risk management Review Hazard identification & hazard characterisation Early alerting systems Fire Services Ambulance services Environment Agency CRCE Local authority 10 Health Protection Team Other (police, NHS, public etc) Recovery role • Interpretation of sampling and modelling results • Environmental clean up advice • Assess long term health effects • exposure assessment • epidemiology • public meetings and reassurance • Support return to normality 11 Chronic enquiries 12 Consultations & planning 13 Carbon monoxide poisoning in restaurants and cafes 14 Carbon monoxide • Tasteless, odourless, colourless gas • Formed during incomplete combustion of fossil fuels: COMPLETE carbon-based + sufficient carbon dioxide fuel O2 (CO2 ) INCOMPLETE carbon-based + insufficient carbon monoxide fuel O2 (CO) 16 17 Presentation title - edit in Header and Footer Acute CO poisoning symptoms Immediate • Headache • Nausea and vomiting • Dizziness, confusion, SOB, blurred vision, loss of consciousness, fits, death Long-term • Brain damage • Damage to heart muscle, skeletal muscle, renal failure • Long-term neurological effects - cognitive and behavioural change • Post-traumatic stress disorder 18 Case study: Acute poisoning •Two adults in a flat above an Indian restaurant felt ill and phoned 999 •Residents reported having flu-like symptoms and visiting GP over a few weeks •Fire service evacuate 7 more people from flats above •All 9 taken to hospital with CO poisoning •No source found in flat… •Source was charcoal burning grill left on overnight while ventilation switched off. 19 Chronic CO poisoning symptoms Immediate • Flu-like illness, sore throat, cough • Low birth weight • Impaired memory, confusion, hearing deficiency, tiredness increased risk of accidents Long-term • Emotional, physical, mental disability • Poor memory, concentration, poor exercise tolerance, apathy, lethargy 20 Case study: Chronic poisoning •Woman in flat has CO detector installed, which goes off repeatedly •Gas engineer finds no problem in house, but detects CO in the kitchen and seating area of restaurant below •Gas supply to restaurant shut down •Over next 6 months, resident’s alarm continues to sound •Source identified as charcoal burning tandoor oven – extractor switched off at night while charcoal smoulders •Resolved when resident becomes so ill and calls emergency services; local authority and CRCE involved 21 Indian restaurant CO levels 22 And other cuisines too! 23 Home-made CO 26 Shisha bars • 12 patients admitted to hospital with CO poisoning • Patients had been at a shisha bar, in the basement • Ambient CO levels 440ppm (fire service) • WHO guideline 25ppm for one hour • Actions: • PHE, council and fire service worked to: • educate shisha lounge owners • enforce health and safety • enforce fire precautions • Used as evidence for the PHE Shisha Toolkit 27 Entertainment venues (that serve food too) 28 Other poisonous gases in catering premises… 30 Refrigerants •What: chemical cooling agents such as ammonia, carbon dioxide, hydrocarbons, isobutane, HCFCs and CFCs •Where: found in fridges, freezers, vending machines, air conditioning units •Risks: cold burns, fires, inhalational risks…ozone layer •Toxicity: mostly low, may cause irritation, dizziness, headaches •Incident examples: • 15 people evacuated after refrigerant leaked in basement of pub, two treated on scene by ambulance for inhalation of fumes • 33 people in Sainsburys taken ill, 50m cordon, one taken to hospital, due to refrigerant leak • Half tonne of ammonia leaked from fractured pipe at food processing plant. Plume blew off-shore 31 Cleaning products 32 Cleaning product fumes •What: usually chlorine; acid fumes / fizzing •Where: anywhere! •Risks: toxic gases, burns, strong odours •Toxicity: depending on chemical and concentration – lung irritation, eye irritation, unconsciousness and death (rare) •Incident examples: • 6 workers at a bar affected by cleaning product, with respiratory problems and burning sensation • Restaurant evacuated due to fumes from mixing chemicals in toilet. Sulphuric acid mixed with something else • Worker and 2 colleagues at food processing site, plus nurses at hospital, showing symptoms after first worker mixed bleach and acid. Patient decontaminated; building evacuated. 33 Heavy metals and food 34 Heavy metals •What: toxic metals, such as lead, cadmium, mercury, arsenic •Where: naturally occurring in rocks, or contamination from anthropogenic action •Toxicity: depends on chemical, dose and route of exposure. Often cumulative •Effects: abdominal pain, anaemia, lower IQ, neurotoxicity, adverse reproductive outcomes, cancers…and many more 35 Heavy metals 36 Regulation of heavy metal contaminants in food •Regulation of heavy metal contaminants in food by FSA surveillance and monitoring •Committee on Toxicity of Chemicals in Food, Consumer Products and the Environment (COT); also COM (Mutagenicity) and COC (Carcinogenicity) •Data: epidemiology, toxicology, No Observed (adverse) Effect Level (if there is one) establish Tolerable Daily Intake •What other sources of exposure are there? Eg water, background levels in air etc •Unavoidable contaminants – what can realistically done to reduce exposure? Eg advise limit weekly intake 37 Unregulated sources in ‘food’ 38 Conclusions • CRCE provides advice in chemical emergencies and to chronic environmental enquiries • Food premises both use and create chemicals, which have the potential to affect public health • Many of the chemical exposures in food premises can be avoided with proper precautions, awareness and training 39 Contact us via your local Health Protection Team Surrey and Sussex: 0345 894 2944 [email protected] 40