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Health care workers unprepared for magnitude of climate change

An epidemic of chronic kidney disease that has killed tens of thousands of agricultural workers worldwide, is just one of many ailments poised to strike as a result of climate change, according to researchers at the University of Colorado Anschutz Medical Campus.

“Chronic kidney disease is a sentinel disease in the era of climate change,” said

Dr. Cecilia Sorensen
Dr. Cecilia Sorensen, lead author of the article in the New England Journal of Medicine.

Cecilia Sorensen, MD, of the Colorado School of Public Health and the University of Colorado School of Medicine. “But we can learn from this epidemic and choose a wiser path forward.”

The article was published today in the New England Journal of Medicine.

Lead author Sorensen and her colleague, Ramon Garcia-Trabanino, MD, said chronic kidney disease of unknown origin or CKDu is now the second leading cause of death in Nicaragua and El Salvador. The death toll from the disease rose 83% in Guatemala over the past decade.

The exact cause of the disease, which hits agricultural workers in hot climates especially hard, remains unknown. It doesn’t align with typical chronic kidney disease which is usually associated with diabetes and hypertension.

“What we do know for certain is that CKDu is related to heat exposure and dehydration,” Sorensen said, adding that exposure to pesticides, heavy metals, infectious agents and poverty may also play a role.

Sugar cane workers in Central America, who often toil in 104-degree heat in heavy clothing, are often victims of the illness.  Sorensen said there is evidence that constant exposure to high temperatures can result in chronic kidney damage.

“They can’t say it’s too hot, they don’t want to go work in the fields,” she said. “If they don’t work, they don’t eat that night.”

The disease is also showing up in the U.S. in places like Florida, California and Colorado’s San Luis Valley.

And the hotter it gets, Sorensen said, the more likely it will increase along with other diseases.

“When it gets hotter, we see more people in emergency rooms with cardiovascular disease,” said Sorensen, who is an emergency department physician at CU Anschutz and a member of the CU Consortium for Climate Change & Health. “We are seeing average global temperatures gradually creep up but one of the biggest risks are heat waves.”

She said U.S. public health officials are not prepared for the kinds of heat waves seen in Europe in 2003 that killed over 70,000 people.

“We are way behind the curve on this compared to Europe,” she said. “We are also seeing Lyme disease in places we never saw it before because the winters are no longer cold enough to kill off the ticks that carry it.”

She said the mosquitos that carry diseases like Zika, dengue fever and Chikungunya are now showing up in the U.S.

“If we are to address both the CKDu and other climate-related diseases, we will have to integrate environmental information into clinical and public health practice and build robust early-warning systems focused on vulnerable communities and climate-sensitive diseases…so we can respond rapidly,” she said. “We believe physicians have the opportunity to change the course of the future.”



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Hitting the streets in hepatitis A battle

Scott Harpin administers shots

With an armed police officer and grocery cart stuffed with backpacks and suitcases behind him, Scott Harpin snapped on his latex gloves and fished out his supplies from a six-pack cooler.

“Which side?” Harpin asked, as he de-capped a needle. His patient tapped his left arm in response and rolled up his sleeve.

“I’ll try to avoid the ink,” Harpin said, quick with some tattoo-related wit designed for relaxing his patient as he aimed the needle just below the man’s left shoulder.

Hardly the sterile, quiet scene of a medical office, Harpin’s mobile clinic environment that bright July morning included trees, fountains and the roar of traffic as he circled Denver’s central Civic Center Park in search of people in need of hepatitis A shots.

Harpin, PhD, MPH, RN, a University of Colorado College of Nursing and Colorado School of Public Health associate professor, joined a volunteer crew of public health workers focused on halting a hepatitis outbreak largely hitting the city’s swelling homeless population.

“This is my chance to come out and be a nurse,” said Harpin, whose research and community service projects focus largely on the nation’s homeless health issues. “I miss the one-to-one contact,” said the popular instructor, whose genuine smile and upbeat personality worked well with the day’s slightly leery clientele.

‘One shot is better than no shot’

“No, I’m good,” a lone woman on a park bench said, rejecting the free vaccine offer after hearing Harpin and his partner’s spiel about the viral liver disease spreading through homeless encampments nationwide.

“Are you sure? We’re in an outbreak. People are getting sick, and it’s really easy to spread,” said Harpin, co-director of the DNP/MPH dual degree program educating tomorrow’s public health nurse leaders.

Scott Harpin gives shot in Denver
Harpin gives a hepatitis A shot to a homeless person in Denver’s Civic Center Park.

The woman shared a common concern expressed that day — the vaccine requires a booster in six months, a tough commitment with a transient lifestyle.

Although the woman stuck with her decision, a few people changed their minds after Harpin explained an initial dose supplied at least 75% protection (up to 95%) against the liver disease. “One shot is better than no shot,” he told them.

Homeless conditions feed outbreaks

The threat is serious, particularly within large homeless populations. The unsanitary conditions of street living feed hepatitis A outbreaks. The virus spreads through infected stool, including via traces on the ground and unwashed hands. Washing hands with soap and water, often hard for people experiencing homelessness, was a chief message of the day.

Other routes of infection include sexual contact, shared smoking materials and IV drug use, with the opioid and homeless crises both boosting infection.

Although rarely fatal, the disease can kill people with compromised livers, such as those already infected with cirrhosis or hepatitis B or C. And it can make people really sick for as long as six months. A 2017 California outbreak centered on its homeless population, infecting 700 people and killing 21.

On the streets: ‘I can’t afford to get sick’

As of July 31 in Colorado, 106 cases and 75 hospitalizations had been reported in the state.

“Shoot me up,” one man said, sticking out his arm, after learning the disease’s transmission routes.

“I don’t want to get sick,” another man said. “I’m out here on the street, and I can’t afford to get sick. My health is already bad enough.”

With upwards of half of Colorado’s 10,000-plus homeless population entrenched in the Denver-metro area, health providers are offering free vaccine clinics across the city until the threat ceases.

Officer helps with team’s success

“This isn’t even the tip of the iceberg,” Denver Police Department Officer Toby Wilson said of the scores of homeless people filling the park.

Wilson works on the Homeless Outreach Team, monitoring and educating people generally in or near the city’s shelters.

Although it was his first time escorting a mobile vaccine clinic, his caring demeanor and ability to connect with people dramatically increased Harpin’s team’s success that day.

“He’s the hero,” Harpin said of Wilson, who, at times, was convincing people to get a vaccine faster than Harpin could keep up.

Volunteers make a difference

“Before we’d even gotten started, he called us over to check out a man who was sick,” Harpin said of Wilson. The man’s yellow skin and eyes were telltale hepatitis signs, and the team gave him a taxi voucher and sent him off for care.

Hepatitis A symptoms

Yellow eyes or skin, diarrhea, pale stools, cola-colored urine, nausea, fatigue.

“It’s an important drop in the bucket for public health,” Harpin said of his couple of hours of work that morning, which he does regularly. “Even if people have already been vaccinated, we are making connections with them and educating them,” he said. “We are letting them know that we are here for them and that we care.”

To volunteer for the city’s campaign, which has resulted in more than 4,200 people being vaccinated since October 2017, contact Allison Seidel at or 303-602-3587.  

Guest contributor: Debra Melani,  CU College of Nursing.

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Greater prevalence of congenital heart defects in areas with high intensity of oil and gas well activity

Mothers living near more intense oil and gas development activity have a 40-70% higher chance of having children with congenital heart defects (CHDs) compared to those living in areas of less intense activity, according to a new study from researchers at the Colorado School of Public Health.

“We observed more children were being born with a congenital heart defect in areas with the highest intensity of oil and gas well activity,” said the study’s senior author Lisa McKenzie, PhD, MPH, of the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus.  At least 17 million people in the U.S. and 6% of Colorado’s population live within one mile of an active oil and gas well site.

Dr. Lisa McKenzie
Lisa McKenzie, PhD, MPH, of the Colorado School of Public Health

The study was published today in the peer-reviewed journal Environment International.

The researchers studied 3,324 infants born in Colorado from 2005-2011. They looked at infants with several specific types of CHDs.

Researchers estimated the monthly intensity oil and gas well activity at mother’s residence from three months prior to conception through the second month of pregnancy.  This intensity measure accounted for the phase of development (drilling, well completion, or production), size of well sites, and production volumes.

They found mothers living in areas with the most intense levels of oil and gas well activity were about 40-70% more likely to have children with CHDs. This is the most common birth defect in the country and a leading cause of death among infants with birth defects. Infants with a CHD are less likely to thrive, more likely to have developmental problems and more vulnerable to brain injury.

Animal models show that CHDs can happen with a single environmental exposure during early pregnancy. Some of the most common hazardous air pollutants emitted from well sites are suspected teratogens – agents that can cause birth defects – known to cross the placenta.

The study builds on a previous one that looked at 124,842 births in rural Colorado between1996-2009 and found that CHDs increased with increasing density of oil and gas wells around the maternal residence. Another study in Oklahoma that looked at 476,000 births found positive but imprecise associations between proximity to oil and gas wells and several types of CHDs.

Those studies had several limitations including not being able to distinguish between well development and production phases at sites, and they did not confirm specific CHDs by reviewing medical records.

The limitations were addressed in this latest study. Researchers were able to confirm where the mothers lived in the first months of their pregnancy, estimate the intensity of well activity and account for the presence of other air pollution sources. The CHDs were also confirmed by a medical record review and did not include those with a known genetic origin.

“We observed positive associations between odds of a birth with a CHD and maternal exposure to oil and gas activities…in the second gestational month,” the study researchers said.

The study data showed higher levels of CHDs in rural areas with high intensities of oil and gas activity as opposed to those in more urban areas. McKenzie said it is likely that other sources of air pollution in urban areas obscured those associations.

Exactly how chemicals lead to CHDs is not entirely understood. Some evidence suggests that they may affect the formation of the heart in the second month of pregnancy. That could lead to birth defects.

McKenzie said the findings suggested but did not prove a causal relationship between oil and gas exploration and congenital heart defects and that more research needs to be done.

“This study provides further evidence of a positive association between maternal proximity to oil and gas well site activities and several types of CHDs,” she said. “Taken together, our results and expanding development of oil and gas well sites underscore the importance of continuing to conduct comprehensive and rigorous research on health consequences of early life exposure to oil and gas activities.”

The study co-authors include William Allshouse, PhD, BSPH and Stephen Daniels, MD, PhD, both of the University of Colorado Anschutz Medical Campus.  The study was funded by a grant from the American Heart Association.

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Tanning industry uses promos, cheap prices to lure adolescents and young adults

Woman laying in tanning bed

It’s well-known that cigarette smoking causes cancer and as a result, prices and advertising are closely regulated to discourage youth from starting.  But another cancer risk, indoor tanning, shown to cause melanoma, lags in regulation.

Researchers at the Colorado School of Public Health have found that the tanning industry uses marketing strategies that appeal to adolescents and young adults, including unlimited tanning packages, discounts, and even offering free tanning when paired with other services like an apartment rental or gym membership.

“This study highlights the fact that a lot of businesses out there are providing this service at a low cost which removes a barrier to adolescents and young adults,” said Nancy Asdigian, lead author of the study and a research associate in the Department of Community and Behavioral Health at the Colorado School of Public Health. “Young people who want to tan do so when they can afford it and don’t when they can’t.  The industry capitalizes on this with the strategies they use to price and promote this risk behavior.”

The study was published this week in the Journal of Public Health Policy.

According to the Global Burden of Disease Study, about 352,000 people worldwide were diagnosed with potentially deadly melanoma in 2015. That includes 81,000 cases in the U.S.

High profile public health and policy efforts along with state age restrictions have helped decrease the prevalence of indoor tanning among youth, but the study said levels remain  `unacceptably high.’

The researchers posed as customers and contacted tanning facilities in Akron, Ohio, Denver, Colorado, Austin, Texas, Boston, Massachusetts, Portland, Oregon and Pittsburgh, Pennsylvania. These cities were selected because they represent a variety of climate and geography as well as a range of stringency of state indoor tanning laws.

Of the 94 tanning places they contacted, 54 were primary tanning salons, and 40 were ‘secondary facilities’ that offered indoor tanning secondary to some other service like hair styling or physical fitness.

The study found that indoor tanning was free at 35 percent of secondary facilities. Nearly all apartments with tanning offered it free compared to 12 percent of gyms. Free tanning was most common in Austin.

Nearly all primary tanning salons offered time-limited price reductions.

“Many provide promos geared toward young adults. They offer packages that incentivize more frequent tanning. The more you use them the cheaper tanning becomes,” Asdigian said. “Everyone wants to get their money’s worth. When you buy a ski pass, you want to ski as much as possible.” In some cases, an individual tanning session could cost as little as $1 if the customer buys an unlimited monthly plan and uses it frequently.

Some countries, including Brazil and Australia, have banned indoor tanning salons altogether. The U.S. imposed a 10% tax on indoor tanning in 2010 and 19 states and the District of Columbia have enacted complete bans on indoor tanning for those under age 18.

But few of these policies have focused on the advertising, promotions or pricing practices of these facilities.

“A next step is to work with policymakers to restrict the use of discounts and deals to lure customers,” said Lori Crane, PhD, MPH, the study’s senior author and professor at the Colorado School of Public Health.

Another strategy would be to eliminate tanning provided in apartment complexes and fitness centers where tanning services are often free and less likely to be licensed and inspected by local regulators.

Asdigian said it’s important to understand the connection between pricing and the use of indoor tanning.

“In this study we described the costs and promotions,” she said. “An important question to answer is how variability in pricing impacts behavior. Establishing that link is an important step.”

The study co-authors include: Yang Lui; Joni A. Mayer; Gery P. Guy and L. Miriam Dickinson.




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Pro cyclist forges new path after traumatic brain injury

Lauren De Crescenzo national champion

At a road cycling race three years ago in Los Angeles, Lauren De Crescenzo’s life changed forever. The pro cyclist was leading a teammate in a down-the-stretch sprint when she flipped over her handlebars at the finish line, landed on her head and suffered a traumatic brain injury.

De Crescenzo was airlifted to a hospital, where the doctors induced a coma for six days. She was then transferred to Craig Hospital in Englewood and she spent five weeks there. When she woke up in the hospital, she had no memory of her fall; her dad had to explain to her what happened. Her spinal injury, it turned out, was just millimeters from leaving her with paralyzed legs.

To say De Crescenzo is determined would be an understatement.

She started studying for the GRE while in the hospital; she just wanted to focus on anything that wasn’t her injury. She enrolled at the Colorado School of Public Health in fall 2017 and graduated last week at the CU Anschutz Medical Campus with a Master of Public Health with a concentration in epidemiology. She had an interest in public health before her accident, minoring in global health during her time as an undergraduate at Emory University.

Lauren De Crescenzo at graduation
Lauren De Crescenzo celebrates receiving her master’s degree from the Colorado School of Public Health at commencement on May 23.

Just this month, De Crescenzo won the USA Collegiate National Time Trial Championship in Georgia.

Asked how long it took to get back on a bike, De Crescenzo said, “Not as long as my parents hoped. I tried to quit, and it lasted about three weeks.” She didn’t want to look at a bike at the rehab center, but a friend, Timmy Duggan, slowly convinced her to get back on a bike.

Duggan, a racer who also suffered from a traumatic brain injury (TBI) in 2009, was her inspiration for her epic comeback. In 2012, he went to the Olympics.

“I’m not ruling it out,” says De Crescenzo, said of her own Olympic aspirations.

Another long-term goal is to be an injury epidemiologist, and she is well on her way. She wants to work in traumatic brain injury prevention as well as possibly conduct research into helmet safety.

Severe depression became a very real consequence of her injury.

“Any big physical trauma comes with mental trauma. That was a big part for me,” she said. “There needs to be an even bigger focus on the emotional, cognitive side effects.”

Going back to school helped her tremendously. Her self-identity changed; before her accident, she thought of herself just as a pro cyclist. Going to school helped her redefine her life and focus her energy on her studies. Her master’s capstone looked at a disease classification manual and how it recorded TBI-related ER visits and hospitalizations.

Her injury put everything into perspective. “Compared to the emotional pain of almost losing everything, physical pain almost doesn’t have an effect on me. The physical pain is temporary and doesn’t seem so bad anymore.” In talking with Duggan she had someone to relate to and didn’t feel so alone. “I wish there was a way for every healthcare professional and researcher to talk to someone who has gone through it because it’s hard to understand the emotional turmoil that it puts you through.”

When asked what she would like to tell someone who has also suffered a TBI, De Crescenzo said, “Never give up. It’s going to get better, and don’t be afraid to get help if you need it.”

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Symposium uses data to clear air-quality debate haze

On May 9, a conference room in the Education 1 building on the University of Colorado Anschutz Medical Campus steadily filled with smoke, ozone, particulate matter and a brew of other pollutants.

Well, not literally. The aforementioned air pollution agents were the focus of an Air Quality & Health Symposium hosted by the Colorado Air Quality Control Commission and the Colorado School of Public Health (ColoradoSPH). A series of speakers presented information about the most significant challenges to Colorado in maintaining safe air quality, including traffic increases, wildfires, accelerating growth and climate change, while the attending commissioners were updated on the latest evidence on air pollution and health.

Colorado is just one player in a global struggle to clean the air, noted ColoradoSPH Dean Dr. Jonathan Samet. After reviewing the scientific evidence and often contentious debate involved in setting air quality standards, Samet offered a blunt observation.

“There are billions around the world not breathing clean air,” he said.

Colorado’s efforts to reduce emissions

The symposium occurred in the aftermath of Colorado’s recently concluded legislative session, which saw passage of a number of bills aimed at reducing emissions that dirty the air. These include House Bill 1261, which establishes goals to reduce greenhouse gas emissions in the state at least 26 percent by 2025 and 90 percent by 2050. In addition, Governor Jared Polis in January issued an executive order supporting a “transition” to zero-emission vehicles in the state.

Jill Hunsaker Ryan
Jill Hunsaker Ryan, executive director of the Colorado Department of Health and Environment, said the transition to zero-emission vehicles in Colorado is “our highest priority.”

That transition is “our highest priority,” Jill Hunsaker Ryan, executive director of the Colorado Department of Health and Environment (CDPHE) told the crowd. “Transportation is the single greatest source of climate-changing emissions.”

Transportation is the only one of the big three sources of greenhouse gas emissions – power sources and the built environment round out the trio – that is expected to grow in the coming years, noted Taryn Finnessey, senior climate change specialist with the Colorado Department of Natural Resources.

Changing our sources of power

“We are changing our sources of power, but we are not necessarily changing the ways that we move as rapidly as we should be,” Finnessey said. She added that steps to “clean up our energy grid” by continuing to adopt renewable sources – there are now more than 57,000 clean energy jobs across the state – work hand-in-hand with electrifying transportation. Construction of charging stations for electric vehicles, begun in 2017, is well underway. Nearly three dozen stations, placed roughly every 50 miles along major highway corridors, are slated to be in place by 2020.

“Start car-shopping,” Finnessey quipped.

Rob McConnell, a professor at the University of Southern California (USC), pointed to the health risks posed by vehicle emissions, particularly to those who live nearby busy roadways. McConnell summarized the findings of USC’s 25-year Children’s Health Study, which followed some 12,000 children living in Southern California.

Researchers used spirometry tests to measure lung function in the participants and established a clear association between abnormally low lung function and living in communities with high particulate levels, McConnell said. The study also showed increased rates of childhood asthma among children who lived within 150 meters of a roadway.

Costs of poor air quality

The costs have been considerable: In Los Angeles County alone, some $400 million annually for asthma exacerbations attributable to pollution, and about half of that tied to near-roadway pollution, McConnell said. In the South Coast Air Basin, which encompasses much of greater Los Angeles, between 430 and 1,300 heart attacks were attributed to near-roadway pollution, generating costs of between $3.8 billion and $11.5 billion, he added.

‘There are billions around the world not breathing clean air.’ – Jonathan Samet, dean of the Colorado School of Public Health

Confronting these sobering statistics should be on the board for Colorado, McConnell said, noting the upcoming widening of I-70. He described steps taken in California to mitigate people’s exposure to pollution near roadways, including expanding mass transit, building high-density housing, and creating parks and other green spaces as buffers.

“By ignoring roadway pollution, we are missing an opportunity to improve air quality,” McConnell said.

Other speakers also noted the health risks posed by polluted air. Dr. Jennifer Peel, a professor of Epidemiology for ColoradoSPH and Colorado State University (CSU), cited data from the Health Effects Institute’s Global 2017 Burden of Disease assessment that pegged the worldwide number of premature deaths tied to fine particulate matter at 3 million. In the United States, the toll was 100,000 lives; in Colorado the number was 650, Peel said.

There is “solid evidence” tying short- and long-term exposure to particles of 2.5 microns (PM2.5) – about one-thirtieth the diameter of a human hair – to cardiovascular and respiratory disease and mortality, Peel said. But evidence is growing that these particles also have adverse effects on the central nervous system, including depression, cognitive decline and autism, she added.

The West Is hotter than ever

Peel cited wildfires as an important source of health-threatening particulate matter. As Finnessey and others noted, fires in Colorado and the West are more frequent and hotter than ever before.

Jonathan Samet at symposium
Dr. Jonathan Samet, dean of the Colorado School of Public Health (far left), fields a question from an audience member at the Air Quality & Health Symposium.

“The size and severity of wildfires has increased significantly over the past four decades,” Finnessey said. “And they are projected to continue to increase.” She noted that “science agrees” that without significant changes, the climate is expected to warm 2 to 6 degrees Fahrenheit by 2050. That rise will contribute to ever-thirstier and more heavily stressed ecosystems that are more vulnerable to prolonged drought and more intense wildfires.

And where there is fire there is smoke that can spread across states and regions. Dr. Colleen Reid, assistant professor in the Department of Geography at CU-Boulder, described her studies of the impacts of wildfires on air pollution and health. She said there is “clear evidence” associating wildfire smoke with respiratory health, including exacerbations of COPD and asthma. More studies of the long-term effects of exposure to wildfire smoke and possible public health interventions are needed, Reid added.

An important part of that effort is figuring out what exactly makes up that smoke. That’s the goal of Dr. Emily Fischer, assistant professor in the Department of Atmospheric Science at CSU. Fischer said wildfires often elevate PM2.5 levels on the ground, creating new emission-control challenges.

“Sporadic smoke events are offsetting improvements in mean PM2.5 air quality in some areas,” Fischer said.

‘Rivers of smoke’

Fischer led a National Science Foundation project called WE-CAN, which aimed to understand wildfire smoke by going to the source. She and fellow CSU scientists boarded a research airplane in 2018 that flew through “rivers of smoke” produced by western wildfires, with the aim of studying the composition of the thick plumes. Among the questions: how does the composition of smoke change as it ages and how does it contribute to rising levels of ozone, another primary air pollution issue.

The efforts to improve air quality also proceed on the ground. Dr. John Volckens, professor of Environmental and Occupational Health for ColoradoSPH and in CSU’s Department of Mechanical Engineering, described work with his team to develop an Ultrasonic Personal Aerosol Sampler (UPAS) that uses cell phone-assisted technology to measure individuals’ exposures to PM2.5. About 1,000 of the relatively inexpensive units are in operation around the globe, Volckens said.

Even more ambitiously, CSU partnered with NASA on a “citizen-science” initiative called CEAMS (Concerned and Engaged Community Members) that set up a network of air-monitoring stations around Fort Collins. The stations, manned by citizen volunteers, gather real-time air-quality data that supplement satellite imaging and the computer analysis that NASA uses to develop predictive air-pollution models.

The information from the monitoring network produced much useful information, Volckens said. For example, the team noticed elevated particle levels in the Old Town section of Fort Collins on cold winter nights. The reason: on those nights, the residents of the mostly old homes were lighting plenty of wood-burning fires.

“Science presents an opportunity to learn more about behavior and about how behavior and exposures [to air pollution] affect each other,” Volckens said. “I think we are only at the beginning of scratching the surface of that opportunity.”

Cleaner air on the horizon

But Volckens also cautioned that changing behavior is no easy task. And while Colorado now has plenty of initiatives on the table to address air-quality issues and climate change, the hard work of implementation is only beginning, Finnessey said.

“The challenge comes in figuring out what this all means and how do we achieve our goals,” she said.

Samet noted the “huge number of adverse” effects attributed to air pollution and the need for science to continue to generate as much evidence as possible about the risks dirty air poses. But in the end, he said, deciding on what to do with the data lies in policymakers’ unpredictable hands.

“The data still leaves those who make the decisions left to make those decisions,” Samet said.

This story was written by guest contributor Tyler Smith.

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Chronic kidney disease epidemic may be result of high heat, toxins

farm workers

A mysterious epidemic of chronic kidney disease among agricultural workers and manual laborers may be caused by a combination of increasingly hot temperatures, toxins and infections, according to researchers at the University of Colorado Anschutz Medical Campus.

The study was published today in the New England Journal of Medicine.

Professor Lee Newman, MD, MA
Professor Lee Newman, MD, MA

In recent years, chronic kidney disease has emerged as a major illness among workers in hot climates. It was first identified in the 1990s by clinicians treating sugar cane workers in Central America. In 2012, it claimed roughly 20,000 lives and has now been identified in California, Florida and in Colorado’s San Luis Valley.

But the exact cause has been hard to determine.

“We looked at all the available literature on the subject and asked, `What do we know today? Where are the gaps?” said the study’s lead author Lee Newman, MD, MA, director of the Center for Health, Work & Environment  and professor in the  Dept. of Environmental & Occupational Health at the Colorado School of Public Health. “We were hoping to synthesize everything we know so far for a framework for moving forward.”

The disease is more prevalent in sugar cane workers and other agricultural employees including cotton and corn workers, shrimp farmers and miners. It is less common at higher elevations.

Newman and study co-author Richard Johnson, MD, of

the University of Colorado School of Medicine, said the disease could be caused by heat, a direct health impact of climate change, as well as pesticides like glyphosate.

“Some pesticides are nephrotoxic, and these could possibly contaminate the water supply,” Johnson said. “Indeed, there are studies showing the epidemic in Sri Lanka is greatest in areas where there are shallow wells in which toxins might become concentrated.”

Dr. Rick Johnson of CU Anschutz
Professor Richard Johnson, MD

Sri Lankan farmers exposed to glyphosate showed an increased risk for chronic kidney disease. Still, the levels in wells were very low and studies in Central America turned up little glyphosate. Along with pesticides, the researchers looked at heavy metals as a possible culprit. Lead and cadmium, known to cause kidney injury, have been reported in the soils of Sri Lanka and Central America.

Other potential causes include infectious diseases that can hurt the kidneys such as the hanta virus and leptospirosis, common in sugar cane workers. Genetic factors are also a possibility.

“The common factors are heat exposure and heavy labor,” Newman said.

Heat stress and persistent dehydration can cause kidney damage.

The disease is moving into the U.S. with agricultural workers in Florida, California’s Central Valley and Colorado’s San Luis Valley reporting incidences of the illness.

“This is not the usual kidney disease we see in the U.S.,” Newman said. “It is not caused by high blood pressure or diabetes. The usual suspects are not the cause.”

Johnson pointed out that CU Anschutz has two major efforts underway that are investigating worker health and the impact of climate change on disease.

“This disease is not confined to the southern hemisphere, it is coming here and in fact it is already here,” Johnson said. “It is my opinion that climate change plays a role in this epidemic.”

Those impacted are mostly agricultural workers, the people who grow and harvest the world’s food.

“They are the people who feed the planet,” Johnson said. “If climate change continues like this who is going to feed us?”

Newman and Johnson believe the epidemic is caused by a combination of heat and some kind of toxin and they recognize the need to take preventative action immediately.  That means ensuring workers get adequate breaks, drink enough fluids and spend time in the shade. It also means maintaining a clean water supply, free of chemicals toxic to the kidneys.

“When clinicians detect clusters of patients with chronic kidney disease who work for the same employer or in similar jobs,” the authors said, “they should contact occupational health and safety and public health professionals to promote investigations of workplace conditions.”

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Researchers find possible connection between cardiovascular disease indicators and living near oil and gas wells

Researchers at the Colorado School of Public Health have found a possible connection between the intensity of oil and gas exploration in an area and early indicators of cardiovascular disease among nearby residents.

In a pilot study of 97 people in Fort Collins, Greeley and Windsor, the scientists found that those who lived in areas of more intense oil and gas development showed early signs of cardiovascular disease (CVD), including higher blood pressure, changes in the stiffness of blood vessels, and markers of inflammation.

Lisa McKenzie, PhD, MPH, of the Colorado School of Public Health
Lisa McKenzie, PhD, MPH, Colorado School of Public Health

The study was published this month in the journal Environmental Research.

“We are not sure whether the responsible factor is noise or emissions from the well pads or something else, but we did observe that with more intense oil and gas activity around a person’s home, cardiovascular disease indicator levels increased,” said the study’s lead author Lisa McKenzie, PhD, MPH, of the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus.

From Oct. 2015 to May 2016, the researchers measured indicators of CVD in 97 men and women from Fort Collins, Greeley and Windsor who did not smoke tobacco or marijuana. The participants did not have jobs that exposed them to dust, fumes, solvents or oil or gas development activities.  None had histories of diabetes, chronic obstructive pulmonary disease or chronic inflammatory disease like asthma or arthritis.  CVD is the leading cause of mortality in the U.S. with more than 900,000 deaths in 2016.

“While behavioral and genetic factors contribute to the burden of CVD, exposure to environmental stressors, such as air pollution, noise and psychosocial stress also contribute to cardiovascular morbidity and mortality,” according to the authors.

John L. Adgate, PhD, MSPH, Colorado School of Public Health
John L. Adgate, PhD, MSPH, Colorado School of Public Health

One increasingly common source of these stressors is extraction of oil and gas in residential areas. Advances in fracking, horizontal drilling, and micro-seismic imaging have opened up many previously inaccessible areas for exploration. Some of those wells are in heavily populated areas. “More than 17.4 million people in the U.S. now live within one mile of an active oil and gas well,” McKenzie said.

Previous studies have shown that short and long-term exposure to the kind of particulate matter emitted from oil and gas operations may be associated with increases in cardiovascular disease and death. At the same time, noise levels measured in communities near these facilities have exceeded levels associated with increased risk of CVD and hypertension, the study said.

This study is the first to investigate the relationship between oil and gas development and CVD. But the results are consistent with an increase in the frequency of cardiology inpatient hospital admissions in areas of oil and gas activity in Pennsylvania.

“Our study findings support the use of these indicators of cardiovascular disease in future studies on oil and gas development in residential areas,” McKenzie said.

Those indicators included blood pressure, arterial stiffening and early markers of inflammation.

McKenzie acknowledged the limitations of the small sample size, saying that the results demonstrate the need for a much larger study.

The study co-authors include: John L. Adgate, Department of Environmental and Occupational Health, Colorado School of Public Health; James Crooks, Division of Biostatistics and Bioinformatics, National Jewish Health, Department of Epidemiology, Colorado School of Public Health; Jennifer L. Peel, Department of Environmental and Occupational Health, Colorado School of Public Health, Department of Epidemiology, Colorado School of Public Health, Department of Environmental and Radiological Health Sciences, Colorado State University; Benjamin D. Blair, Department of Environmental and Occupational Health, Colorado School of Public Health; Stephen Brindley, Department of Environmental and Occupational Health, Colorado School of Public Health; William B. Allshouse, Department of Environmental and Occupational Health,

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Looking ahead to Public Health 4.0

Faculty, students, staff and friends of the Colorado School of Public Health (ColoradoSPH) gathered Nov. 28 for an annual event with a special twist. The “State of the Sc­­hool” address, led by Dean Jonathan Samet, MD, MS, included an acknowledgement and celebration of the school’s 10th anniversary.

As Samet noted, a “free” gift was on hand for attendees in the Nighthorse Campbell Native Health Building’s Shore Auditorium: an 86-page 10th anniversary magazine, titled with the school’s anniversary tagline, “Charting New Paths for a Healthier Future.” The publication’s 28 pieces highlight the school’s wide range of education, practice and research at the University of Colorado, Colorado State University, and the University of Northern Colorado.

“It’s a 10-year panorama of what has happened at the school,” Samet said, joking that after 409 days on the job, “I can still call myself a new dean.”

Past, present, future

10th anniversary at ColoradoSPH
Attendees of the Colorado School of Public Health’s 10th anniversary snapped up editions of the school’s 10th anniversary magazine, “Charting New Paths for a Healthier Future.”

Samet used his presentation to engage his audience and to pivot between the past, the present and the future. A sheet of paper with three questions about what they would do to direct the future of the school awaited people at their seats, along with a decidedly old-school item.

Saying “I’ve given you a little bit of homework,” Samet held up a stubby pencil. “This is a pencil,” he jokingly said. “If you’re not sure how to use it, ask someone who is age-appropriate.”

With that, Samet briefly reviewed the history and progress of the public health field, noting that the number of public health degrees conferred in the United States has more than quadrupled over the last 25 years. Over the school’s first 10 years, ColoradoSPH has graduated a total of about 2,000 students, he added, with roughly 500 Master of Public Health (MPH) degree-seeking students currently enrolled.

Fast-growing field

“Public health has grown,” Samet said. “We’re part of that growth.”

He underscored the school’s commitment to its education mission with a quick review of a few of the many recent capstone projects and papers produced by students and graduates and a nod to new educations initiatives including a PhD program in Health Economics, an MPH concentration in Population Mental Health and Wellbeing, and several new public health certificate programs in Latino health, mental health and wellbeing, and applied biostatistics, as well as a developing certificate in American Indian and Alaska Native health.

‘We need to have extended interactions with communities in new ways, some of them data-driven.’ – Dean Jonathan Samet

Of course, a major goal of public health education is to get graduates into the field. Samet pointed out that 97 percent of the school’s graduates were employed or seeking further education within one year of receiving their degrees. He singled out the school’s Center for Public Health Practice, led by Cerise Hunt, PhD, for its initiatives in local, rural and regional public health workforce training programs – including 222 online and in-person trainings over the last year that have served more than 9,500 people.

A mix of funding from the National Institutes of Health (NIH) and other sources makes up $34.8 million to support research, another key component of the school’s mission. He also noted that private philanthropic support totaled more than $9 million in 2018, bolstering efforts in faculty recruitment, student scholarships and attention to public health policy.

Challenges ahead

Samet spent a good part of the session with an eye toward the next decade. Looking to the challenges facing public health professionals, Samet said that ongoing issues, including obesity, diabetes, mental health, substance use disorders and tobacco use, will continue to require close attention. But he added that “there are new things that are always emerging. That is the nature of public health.” He listed risks posed by oil and gas drilling, marijuana use, vaping and urbanization leading to the closing of rural hospitals as examples.

He also ticked off a number of “personal priorities,” including “advancing diversity” among the student body, increasing “synergies” across the three campuses and continuing to build close relationships with the people and public health officials across the state and region.

“We need to step back and say, ‘Does our university reflect the communities around us, the communities of need, the communities that we really want to focus on in advancing public health?’” Samet said.

Lively discussion

Through the talk, Samet encouraged back-and-forth discussions about the three questions he had posed for paper-and-pencil pondering. What would your highest priority be if you were Dean for the day? With a gift of $10 million to the school, what would be your priority areas for spending it? What are the two areas that need the most attention for strategic planning?

toasting the 10th anniversary of the ColoradoSPH
Attendees of the State of the School address enjoyed a non-alcoholic celebratory toast to mark the 10th anniversary of the Colorado School of Public Health.

The answers ranged widely: constructing a dedicated building for the school; increasing support for fellowships and scholarships; responding more aggressively to the social determinants of health; beefing up marijuana research; building relationships with incoming legislators; probing mental health issues; responding to the impacts of climate change – and more.

The conversation continued in this vein when Samet said he’d obtained an advance copy of the 20th anniversary magazine. “I’d like to show you a little bit of that,” he said, starting with an artist’s rendering of a brand-new ColoradoSPH building. “It might be a bit garish,” Samet conceded. But the publication-to-be also looked forward to what he called “Public Health 4.0,” the next generation of challenges for the field.

Public Health 4.0

“What will Public Health 4.0 be?” an audience member asked. Samet said he sees it resting on “two pedestals,” the first being the need to gather more and more data from increasingly sophisticated technology and figure out “the useful signals from that data.” Second, “We need to have extended interactions with communities in new ways, some of them data-driven. I think we will see that the public health community will recognize that a lot of the things we do are going to require greater engagement with communities.”

Before adjourning to the auditorium lobby for a non-alcoholic celebratory toast, Samet received a folded American flag, encased in glass, from Jamila Bryant, a 2017 graduate of the school’s MPH program at Colorado State University. Bryant, a Master Sergeant in the U.S. Air Force Reserves, recently served a six-month deployment to the Al Dhafra Air Base in the United Arab Emirates. The flag she presented to the ColoradoSPH was flown on Feb. 22, 2018, during a mission in support of Operation Inherent Resolve, a multinational coalition committed to the defeat of the Islamic State of Iraq and the Levant, a group designated as a terrorist organization by the United Nations.

Bryant presented the flag and a certificate to Dean Samet to spirited applause from the school’s audience in attendance.

Guest contributor: Story written by Tyler Smith. Photos by Brett McPherson.

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Patients who used psychotropic drugs in suicide attempts were more likely to have had prescriptions for them

As prescriptions for psychotropic drugs increase, researchers at the University of Colorado Anschutz Medical Campus have found that prescribed access to anti-anxiety and anti-psychotic medications may make it easier for some patients to use the drugs in attempted suicides.

“In a study focused on people who attempted suicide, those who used a psychotropic drug in an attempt were 70 percent more likely to have prescribed access than patients who used other methods in their attempt,” said Talia Brown, MS, PhD, lead author of the study from the Colorado School of Public Health at CU Anschutz.

Talia Brown, MS, PhD, lead author of the study from the Colorado School of Public Health
Talia Brown, MS, PhD, lead author of the study from the Colorado School of Public Health.

The study was published last week in the Journal of Clinical Psychiatry.

Suicide is the 10th leading cause of death in the nation with 45,000 fatalities in 2016, more than 200,000 hospitalizations and 500,000 emergency department visits.

Survival often depends on the method used and the method usually depends on having physical access to it. Intentional poisoning accounts for 15 percent of all fatal suicides and between 54-68 percent of nonfatal suicide attempts. Drugs make up the vast majority of those poisonings.

The study investigated the association between prescribed access to psychotropic drugs and using them in a suicide attempt. The researchers used a large, nationally representative insurance claims dataset of 27,876 people who had attempted suicide at least once.

They found that 10,158 of them had used psychotropic drugs in their attempt. The most commonly used were antianxiety medications, followed by antidepressants, antipsychotics or mood stabilizers and stimulants. About 13 percent used more than one drug.

Overall, some 23 percent of those in the study who used psychotropic drugs in a suicide attempt had filled prescriptions for the drugs within 90 days before their suicide attempt. That led researchers to ask how so many other people who attempted suicide gained access to the medications they took.

Heather Anderson, PhD, associate professor in the Center for Pharmaceutical Outcomes Research at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
Heather Anderson, PhD, associate professor in the Center for Pharmaceutical Outcomes Research at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences

“The most likely options were from family and friends, previous prescriptions filled prior to our exposure period, medications purchased outside of insurance plans or on the black market,” the study said.

Brown said it was important to safely store all over-the-counter and prescription drugs, not just the most toxic, especially when there is a friend or family member at risk of suicide.

The findings offer a number of lessons and insights into prescribing these drugs, said the study’s senior author Heather Anderson, PhD, associate professor in the Center for Pharmaceutical Outcomes Research at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences.

“Restricting or modifying access to psychotropic drugs will require increased attention by all healthcare professionals, particularly pharmacists who are well-positioned to talk to their patients about safe medication use and storage,” she said. “It is important to stay on top of a patient’s depression, stay on top of their prescriptions and monitor suicidal ideation.”

Providing medicine in blister packs has been successful in other countries in reducing deaths because it requires time and effort to remove enough of the drug for an overdose. And people can change their minds during that time.

Ultimately, Brown said, those at high risk for suicide with prescriptions for psychotropic drugs should be closely monitored for potential safety interventions.

The study co-authors include: Peter M. Gutierrez, PhD; Gary K. Grunwald, PhD; Carolyn DiGuiseppi, MD, PhD; Robert J. Valuck, PhD.

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