CHILDREN AND CHEMICALSCHILDREN AND CHEMICALS
TRAINING FOR THE HEALTH SECTORTRAINING FOR THE HEALTH SECTOR [Date …Place …Event…Sponsor…Organizer] [Date …Place …Event…Sponsor…Organizer]
Children's Health and the EnvironmentChildren's Health and the EnvironmentWHO Training Package for the Health SectorWHO Training Package for the Health Sector
World Health OrganizationWorld Health Organization
www.who.int/cehwww.who.int/ceh
CHILDREN AND CHEMICALSCHILDREN AND CHEMICALS
October 2011 October 2011 1
Children and chemicalsChildren and chemicals
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Learn about chemical hazards – what they are and the risks they may pose to children
Identify the scenarios – how, where and when are children exposed?
Recognize signs, symptoms and diseases due to acute and chronic toxic exposures in children
Know how to assess, prevent and treat children's toxic exposures
LEARNING OBJECTIVES
Children and chemicalsChildren and chemicals
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CHEMICALS AMONG OTHER GLOBAL ENVIRONMENTAL CHEMICALS AMONG OTHER GLOBAL ENVIRONMENTAL HEALTH ISSUESHEALTH ISSUES
Chemical hazards Air pollution - indoor and outdoor Household water insecurity Poor hygiene and sanitation Disease vectors Injuries and accidents Emerging issues
- Climate change
- POPs
- Ozone layer
WHO
Children and chemicalsChildren and chemicals
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CHEMICALS ARE USED IN EVERYDAY LIFECHEMICALS ARE USED IN EVERYDAY LIFE
Benefits Promote hygiene
Protect crops
Control vectors
Risks Adverse health effects
Unwanted pollutants in the environment
Persistence
WHO
Children and chemicalsChildren and chemicals
Acute and chronic, high and low-level exposures to chemicals in the environments of children may cause functional and organic damage, during periods of special vulnerability
“Children are not little adults”…
Informed health care providers play a key role in preventing and managing diseases
CHILDREN AND TOXICANTSCHILDREN AND TOXICANTS
WHO
Children and chemicalsChildren and chemicals
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EXPOSURE TO CHEMICALS AT HOME, SCHOOL, EXPOSURE TO CHEMICALS AT HOME, SCHOOL, PLAYGROUND, FIELDS & STREETSPLAYGROUND, FIELDS & STREETS
Different exposures expected from rural and urban settings by:
Household products, building materials, house dust, food contaminants, and toys
Pharmaceuticals, cosmetics, and hygiene products
Second-hand smoke
Workplace (of the parents, or the child, "take home" exposures)
Persistent Organic Pollutants (POPs) in the environment
Chemicals of natural origin: e.g: fluoride in water, aflatoxins, cyanide, pyrrolizidine alkaloids
Mixed chemicals
Children and chemicalsChildren and chemicals
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CHILDREN'S CHEMICAL EXPOSURES ARE CHILDREN'S CHEMICAL EXPOSURES ARE MAGNIFIED IN DEVELOPING AND MAGNIFIED IN DEVELOPING AND
TRANSITIONAL COUNTRIESTRANSITIONAL COUNTRIES Unsafe use of chemicals
Increasing pollution and uncontrolled use of chemicals
Chemical dumping
Additional factors: malnutrition, infectious diseases, poverty
Child work and scavengers
Lack of awareness of risks
Lack of interest
Despair at the magnitude of the problem
Children and chemicalsChildren and chemicals
Developmental Physiology•Increased energy requirements
•Different metabolism•Windows of susceptibility
Longer lifeand latency
Politically Powerless
Unique Exposures•Unique pathways
•Behaviors•Poor understanding•Microenvironments
VULNERABILITYVULNERABILITY OF CHILDRENOF CHILDREN
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EFFECTS
Organs
Systems
Functions
Development
RISKS
Physical
Chemicals
Biological
MEDIA
Water - Air - Food - Objects
SETTINGSURBAN & RURAL
Home
School
Playground
Field
Street
WorkplaceCIRCUMSTANCES
Eating, Drinking, Playing, Learning, Working, Scavenging
CHILDREN'S COMPLEX ENVIRONMENTCHILDREN'S COMPLEX ENVIRONMENT
Ceppi, Corra
VULNERABILITYDynamic, developmental physiology and "windows of vulnerability"
Children and chemicalsChildren and chemicals
TOXICOKINETICSTOXICOKINETICS AND TOXICODYNAMICSAND TOXICODYNAMICS
Toxicokinetics - all the processes and pathways that a substance goes through in the body
Toxicodynamics the interaction between a substance and the body, resulting in toxic effects
Simply stated, toxicokinetics refers to what the body Simply stated, toxicokinetics refers to what the body does to the toxin, while toxicodynamics refers to does to the toxin, while toxicodynamics refers to what the toxin does to the bodywhat the toxin does to the body
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How are xenobiotics handled by an immature,
anabolic body?
Absorption
Energy, water, oxygen consumption
Biotransformation
Activation/detoxification
Distribution
Fat
Blood-brain barrier
Elimination
Critical windows of development
Development of organs and systemsWHO
TOXICOKINETICSTOXICOKINETICS
Children and chemicalsChildren and chemicals
12 Moore, Elsevier Inc, 1973
DYNAMIC DEVELOPMENTAL PHYSIOLOGYDYNAMIC DEVELOPMENTAL PHYSIOLOGYWINDOWS OF DEVELOPMENTWINDOWS OF DEVELOPMENT
Children and chemicalsChildren and chemicals
TRANS-GENERATIONALTRANS-GENERATIONAL TOXICANTSTOXICANTS
Exposure occurs during youth
Prolonged half lives (up to 10 years)
As women enter childbearing years the toxicant moves transplacentally and has adverse effects on development
Examples:
• Polychlorinated biphenyls (PCBs) - Yusho and Yu-cheng
• Methyl mercury- Iraq
Prevention is key
Children and chemicalsChildren and chemicals
Maternal exposure to: Mercury, ethylene oxide, rubber chemicals, solvents, are linked to
spontaneous abortion
Pre-conception PCBs and lead maternal body burdens are linked to abortion, stillbirth and
learning disabilities Folate deficiency leads to neural tube defects
In utero exposures:Thalidomide phocomeliaX-rays leukaemia Heat neural tube defects Alcohol FAS (fetal alcohol syndrome)Lead Neurodevelopmental effectsMethyl mercury Neurodevelopmental effects
DEVELOPMENTAL PHYSIOLOGY:DEVELOPMENTAL PHYSIOLOGY: PARENTS AND THEIR OFFSPRINGPARENTS AND THEIR OFFSPRING
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Children and chemicalsChildren and chemicals
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TOXICODYNAMICSTOXICODYNAMICSHOW DO TOXIC EFFECTS OCCUR?
During critical windows of exposure
On critical organs/systems
Central nervous system (CNS)
Immune system
Endocrine system
Other organs
A child is building the body for a “lifetime”.
WHO
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ROUTES OF EXPOSUREROUTES OF EXPOSURE
Unique exposure pathways Transplacental Breastfeeding
Exploratory behaviors leading to exposure Hand-to-mouth, object-to-mouth Non-nutritive ingestion
Stature and living zones, microenvironments Surface area to volume ratio
Children do not understand danger Pre-ambulatory Adolescents have “high risk” behaviors
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Water• Drinking• Recreational
Air• Indoor• Outdoor
Food
Cosmetic and hygiene products
Objects and toys
MEDIA OF EXPOSUREMEDIA OF EXPOSURE
WHO
PAHO
Children and chemicalsChildren and chemicals
Poverty limits adaptive responses to both climate change and chemical exposures.
Malnutrition may compound and worsen effects from toxic exposure.
Geography is a major determinate of which health threats from climate change are most likely, and places entire populations at increased risk.
Occupations that involve the use of chemicals, such as agricultural work, may be increasingly risky because of increased chemical use, change in chemicals used and rapid development of new chemicals.
Public health infrastructure, chemical safety laws, regulations, surveillance and enforcement, are critical to minimizing injury and illness related to climate change and chemical exposures.
CLIMATE CHANGE AND CHEMICALSCLIMATE CHANGE AND CHEMICALS
Children and chemicalsChildren and chemicals
TOXIC SUBSTANCES IN TOYS AND ARTICLESTOXIC SUBSTANCES IN TOYS AND ARTICLES
Toys: lead, cadmium and phthalates
Jewellery: lead, cadmium
Electronic products: lead, mercury, cadmium, and brominated flame retardants
Batteries: lead and other heavy metals
Textiles : perfluorinated compounds in waterproof garments, nonylphenol ethoxylates as surfactants
Furniture : fungicides
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U.S. Environmental Protection Agency
Children and chemicalsChildren and chemicals
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Anthropogenic "man-made" Industry Traffic Additives and contaminants Contaminated areas
Natural Arsenic Fluoride Plants Aflatoxins Blue-green algae
SOURCES OF EXPOSURE IN THE ENVIRONMENTSOURCES OF EXPOSURE IN THE ENVIRONMENT
WHO
Ceppi, Corra
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Unintentional ("accidental")
Intentional
Iatrogenic
Occupational
‘Take-home’
ENVIRONMENTAL
CIRCUMSTANCES OF EXPOSURECIRCUMSTANCES OF EXPOSURE
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PrenatalPrenatal
NewbornsNewborns
ToddlersToddlers
School childrenSchool children
AdolescentsAdolescents
SCENARIOS OF SCENARIOS OF EXPOSURE :EXPOSURE :AGE AGE ANDAND GENDER GROUPS GENDER GROUPS
WHO
Corra
WHO
WHO
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Acute: Exposure over a short period of time (e.g. 24 hours)
Single: a single or unique and continuous exposure Repeated: multiple exposures; potential accumulation
Chronic or long-termContinuous or repeated exposure (e.g. more than 24 hours, for weeks or months)
"Acute on chronic" An acute exposure against a background of chronic exposure to the same agent
"Hit and run" Acute exposure leading to delayed effects once the toxicant is gone
TYPE OF EXPOSURETYPE OF EXPOSURE
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High-dose exposure poisoning
Low-dose exposure subtle effects
(more recently recognized)
Concern raised by persistent organic pollutants (POPs) and potential developmental neurobehavioral and endocrine effects
HIGH AND LOW DOSE EXPOSURESHIGH AND LOW DOSE EXPOSURES
Subtle effects do not equal minor effects!
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CLINICAL AND SUBCLINICAL EFFECTSCLINICAL AND SUBCLINICAL EFFECTS
Clinical features observed depend upon:
Agent (chemical, physical, biological)DoseTiming and length of exposure
May be:
Asymptomatic Acute and evident: toxic syndromes Chronic and subtle: undefined symptoms Detected only by laboratory studies
WHO
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According to Poisons Centres :
Up to 50% to 70% of the calls are about children exposed to chemicals or actually poisoned
Number of poisoning cases is underestimated
Cases of exposure are mostly acute and accidental
The majority are between 1 & 4 years old
Boys are more affected
The outcome is usually favourable
Mortality is usually low
ACUTE POISONINGSACUTE POISONINGS
U.S. Environmental Protection Agency
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Pharmaceuticals: sedatives, analgesics, contraceptives syrups, contaminants
Household products: bleaches, cleaners, detergents, solvents, kerosene (paraffin)
Cosmetics: perfumes, shampoo, nail products
Plants and mushrooms: berries, seeds, leaves
Drugs of abuse: alcohol, illicit drugs of abuse, tobacco
Pesticides: insecticides, rodenticides, herbicides
Bites and stings: "envenoming" by snakes, scorpions, spiders, bees
CHEMICALS –CHEMICALS – ACUTE POISONINGSACUTE POISONINGS
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ACUTE POISONINGSACUTE POISONINGS
Pharmaceuticals: one teaspoon or pill can be dangerous!
• Benzodiazepines• Tricyclic antidepressants• Codeine• Diphenoxylate (Lomotil)• Theophylline• Antidiabetic sulfonylureas• Digitalis • Antihypertensives• Methyl salicylate• Iron
• Quinidine• Chloroquine• Lindane• Camphor
WHO
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PESTICIDES PESTICIDES
Spraying of pesticides at home and in schools increases exposure to children due to: Higher concentrations near the floor
Persistence in some surfaces, such as carpets and soft toys
Overuse and misuse of pesticides
Children activities contribute to inhalation of pesticides Crawling
Playing close to the floor
Hand-to-mouth and
object-to-mouth activities
WHO
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SOLVENTS & VOLATILE ORGANIC COMPOUNDSSOLVENTS & VOLATILE ORGANIC COMPOUNDS
Aromatic hydrocarbons, alcohols, aldehydes, ketones.
Sources: Solvents, fabric softeners, deodorizers and cleaning products
Paints, glues, resins, waxes
and polishing materials
Spray propellants, dry
cleaning fluids
Pens and markers
Binders and plasticizers
Cosmetics: hairspray, perfumes U.S. Environmental Protection Agency
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Pesticides
Metals
Lead, Arsenic, Mercury
Other heavy metals
Persistent organic pollutants (POPs)
CHEMICALS: CHRONICCHEMICALS: CHRONIC EXPOSUREEXPOSURE
Children and chemicalsChildren and chemicals
PESTICIDES: CHRONICPESTICIDES: CHRONIC EXPOSUREEXPOSURE
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Child-care centres
Schools
Children spend hours Close to the ground Touching and tasting Pesticides applied remain in carpets and fabrics.
Levels of chlorpyrifos vapours in the child’s breathing zone (25 cm) are 94 microg/m3 but in the adult’s breathing zone (100 cm) are 64 microg/m3
Exposure of neonatal rats to chlorpyrifos produced brain cell damage and loss, with resultant abnormalities of synaptic development.
WHO
Children and chemicalsChildren and chemicals
LEAD TOXICITY: CHRONICLEAD TOXICITY: CHRONIC EXPOSUREEXPOSURE
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Agency for Toxic Substances and Disease Registry
Children and chemicalsChildren and chemicals
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Confirm exposure to toxicants
Determine magnitude / severity
Assess and measure effects
Monitor the efficacy of treatment
Follow up the clinical evolution
ROLE OF THE LABORATORYROLE OF THE LABORATORY
WHO
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Acute (e.g. Organophosphorus Pesticide): Resuscitation (intubation, ventilation, life-saving measures) Decontamination Symptomatic treatment Specific treatment: use of antidotes or antagonists
Chronic / low-level exposure (e.g. lead) requires: Removing the child from the source of exposure Symptomatic treatment Specific treatment: use of antidotes, if appropriate Follow-up treatment (long term) Remedial measures to environment
Important: Consult the Poison Centre !
TREATMENT OF TOXIC EXPOSURESTREATMENT OF TOXIC EXPOSURES
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PREVENTION OF EXPOSURE IS THE SINGLE MOST EFFECTIVE PREVENTION OF EXPOSURE IS THE SINGLE MOST EFFECTIVE MEANS OF PROTECTING CHILDREN AGAINST TOXICANTSMEANS OF PROTECTING CHILDREN AGAINST TOXICANTS
Identifying the problem
Defining its determinants and characteristics
Informing the community – and the children!
Educating colleagues and other professionals
Raising the awareness of policy-makers
Promoting the implementation of the appropriate measures
Helping to evaluate the efficacy of preventive measures
WHO
Health care providers play a key role in:
Children and chemicalsChildren and chemicals
CASECASE STUDY: THAI SCHOOLCHILDREN AND STUDY: THAI SCHOOLCHILDREN AND PESTICIDESPESTICIDES
Schools aim to identify toxic pesticides available in the farming communities and the hazardous uses
Children also assess the acute health effects suffered by their parents by conducting a health history and examination before and after spraying.
Goal is to raise awareness among children and their parents about the hazards of pesticides and to eliminate exposure and the resulting adverse health effects
Children and chemicalsChildren and chemicals
CASECASE STUDY: THAI SCHOOLCHILDREN AND STUDY: THAI SCHOOLCHILDREN AND PESTICIDESPESTICIDES
Results: Household pesticide storage and disposal practices improved. Initially, students identified that pesticides were stored in areas
where children played After 4 months, the proportion of houses defined as “child unsafe”
had decreased from 64% to 45%. Pesticide storage and disposal that were potentially contaminating
food, water and livestock improved by 31%, 22%, and 20%respectively.
Homes recycling pesticide containers diminished from 16% to 5%. Students reported that their parents took greater care to protect
themselves during spraying. All wore rubber gloves and boots and none smoked during the spray operation.
Of the 18 signs and symptoms of health effects initially reported by parents, all but two decreased in frequency.
Children and chemicalsChildren and chemicals
Ensure safe storage, packaging, clear labelling, of cleaners, fuels, solvents, pesticides and other chemicals used at home and in school.
Promote the use of child-resistant packages for pharmaceuticals and for chemical products.
Inform parents, teachers and child-minders about the potential chemical hazards in the places where children spend their time.
Train healthcare providers on the recognition, prevention and management of toxic exposures, and on the use of the paediatric environmental history to investigate specific risks to which children are exposed.
Incorporate the teaching of chemical safety and health into school curricula.
PROTECT CHILDREN FROM ALL CHEMICAL HAZARDSPROTECT CHILDREN FROM ALL CHEMICAL HAZARDS
Children and chemicalsChildren and chemicals
Create and enforce legislation to promote the safe use and disposal of chemicals.
Promote policies to reduce and remedy environmental pollution.
Avoid the construction of homes, schools and playgrounds near polluted areas and hazardous installations.
Poisons, medicines, bleach, acid, and liquid fuels such as kerosene should never be stored in drinking bottles. All such liquids and poisons should be kept in clearly marked closed containers out of children's sight and reach
PROTECT CHILDREN FROM ALL CHEMICAL HAZARDSPROTECT CHILDREN FROM ALL CHEMICAL HAZARDS
Children and chemicalsChildren and chemicals
Publications for all audiences: health professionals, scientists, policy-makers, communities www.who.int/ceh www.who.int/ipcs/en/
Summary of Principles for Evaluating Health Risks
in Children Associated with Exposure to Chemicals Training package on child health and environment Birth cohort studies initiative National profiles on child health and environment Pediatric environmental health history UNEP/WHO Toxicology in the classroom toolkit for schoolchildren
www.chem.unep.ch/Pesticides/ToxicologyInTheClassroom/default.htm
PROTECT CHILDREN FROM ALL CHEMICAL HAZARDSPROTECT CHILDREN FROM ALL CHEMICAL HAZARDS
WHO TOOLS AVAILABLEWHO TOOLS AVAILABLE
www.who.int/cehwww.who.int/ceh
www.who.int/ceh
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1992 Agenda 21, Ch. 25 (United Nations Conference on Environment and Development) www.un.org/esa/sustdev/documents/agenda21/index.htm
1997 Declaration of the Environment Leaders of the Eight on Children’s Environmental Health yosemite.epa.gov/ochp/ochpweb.nsf/content/declara.htm
1999 Declaration of the Third European Ministerial Conference on Environment and Health www.who.dk/AboutWHO/Policy/20010825_2
2002 Bangkok Statement (WHO International Conference) www.who.int/ceh
2003 Recommendations of the Intergovernmental Forum on Chemical Safety (IFCS) on Children and Chemicals www.ifcs.ch
2004 Budapest Ministerial Conference on Environment and Health (CEHAPE) www.euro.who.int/__data/assets/pdf_file/0006/78639/E83338.pdf
SOME INTERNATIONAL AGREEMENTS ON THE SOME INTERNATIONAL AGREEMENTS ON THE PROTECTION OF CHILDREN'S HEALTH FROM PROTECTION OF CHILDREN'S HEALTH FROM
THE EFFECTS OF CHEMICALSTHE EFFECTS OF CHEMICALS
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2004 Health and Environmental Ministerial Meeting of the Americas (HEMA)
2005 Buenos Aires Declaration (2nd WHO, International Conference) – www.who.int/ceh
2009 Declaration of the Environment Leaders of the Eight on Children’s Environmental Health
2009 Busan Pledge for Action (3rd WHO International Conference) – www.who.int/ceh
Health and Environment Ministerial meetings in WHO regions (Africa, Western Pacific, …) – www.who.int/phe
SOME INTERNATIONAL AGREEMENTS ON THE SOME INTERNATIONAL AGREEMENTS ON THE PROTECTION OF CHILDREN'S HEALTH FROM PROTECTION OF CHILDREN'S HEALTH FROM THE EFFECTS OF CHEMICALS …CONTINUEDTHE EFFECTS OF CHEMICALS …CONTINUED
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Learn about chemical hazards in children – what they are and what are the risks they may pose?
Identify the scenarios – how, where and when are children exposed?
Recognize signs, symptoms and diseases that may be related to acute and chronic toxic exposures in children
Know how to assess, prevent and manage children's toxic exposures
WERE THE LEARNING OBJECTIVES REACHED?WERE THE LEARNING OBJECTIVES REACHED?
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First draft prepared by Jenny Pronczuk MD (WHO)
With the advice of the Working Group Members on the Training Package for the Health Sector: Cristina Alonzo MD (Uruguay); Yona Amitai MD MPH (Israel); Stephan Boese-O’Reilly MD MPH (Germany); Stephania Borgo MD (ISDE, Italy); Irena Buka MD (Canada); Ernesto Burgio (ISDE, Italy); Lilian Corra MD (Argentina); Ligia Fruchtengarten MD (Brazil); Amalia Laborde MD (Uruguay); Jenny Pronczuk MD (WHO) Christian Schweizer TO (WHO/EURO); Kathy Shea MD (USA).
Reviewers: Ligia Fruchtengarten MD (Brazil); Josef G. Thundiyil MD, MPH (USA), Renee Modica MD, MSEd (USA), Carolyn Vickers MSc (WHO), Dr Huw Brunt (UK), Prof Gary Coleman (UK), Dr Raquel Duarte-Davidson (UK), Dr Elaine Lynch Farmery (UK), Alison M Good BSc Dip Med Tox MSc (UK), Dr Mark Griffiths (UK), Dr John Thompson (UK), Dr Laura Yates (UK)
WHO Project coordination: Ruth A. Etzel, MD PhDMarie-Noël Bruné, MSc
Latest update: October 2011 (H. Graczyk, L. Tempesta)
ACKNOWLEDGEMENTSACKNOWLEDGEMENTS
WHO is grateful to the US EPA Office of Children’s Health Protection for the financial support WHO is grateful to the US EPA Office of Children’s Health Protection for the financial support that made this project possible and for the data, graphics and text used in preparing these that made this project possible and for the data, graphics and text used in preparing these
materials. Further support was kindly provided by the UK Department of Health.materials. Further support was kindly provided by the UK Department of Health.
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DISCLAIMERDISCLAIMER The designations employed and the presentation of the material in this publication do not imply
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The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The opinions and conclusions expressed do not necessarily represent the official position of the World Health Organization.
This publication is being distributed without warranty of any kind, either express or implied. In no event shall the World Health Organization be liable for damages, including any general, special, incidental, or consequential damages, arising out of the use of this publication
The contents of this training module are based upon references available in the published literature as of its last update. Users are encouraged to search standard medical databases for updates in the science for issues of particular interest or sensitivity in their regions and areas of specific concern.
If users of this training module should find it necessary to make any modifications (abridgement, addition or deletion) to the presentation, the adaptor shall be responsible for all modifications made. The World Health Organization disclaims all responsibility for adaptations made by others. All modifications shall be clearly distinguished from the original WHO material.