revista pan american panamericana journal of de salud pÚblica public health · 2016-06-24 ·...

REVISTA PAN AMERICANPANAMERICANA JOURNAL OFDE SALUD PÚBLICA PUBLIC HEALTH

Supplementary material to: Haby MM, Soares A, Chapman E, Clark R, Korc M, Galvão LAC. Interventions that facili-tate sustainable development by preventing toxic exposure to chemicals: an overview of systematic reviews. Rev Panam Salud Publica. 2016;39(6):378–86.

This material formed part of the original submission and has been peer reviewed.We post it as supplied by the authors.

Material suplementario / Supplementary material / Material supplementar

SUPPLEMENTARY MATERIAL Haby et al. • Interventions that facilitate sustainable development by preventing toxic exposure to chemicals

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Supplementary File 1. Excluded systematic reviews (Table A1a) and economic evaluations (Table A1b).

Table A1a. Systematic reviews excluded at full-text stage (n=40)

Review Reason/s for exclusion

Bauer et al. (2010) Interventions – not primarily aimed at prevention of toxic exposure to chemicals but to mild irritation mostly caused by wet working conditions. Mostly individual level interventions - barrier cream, moisturizer, gloves.

Bierkens et al. (2012)

Study type - not a systematic review as no inclusion criteria used. Intervention - none applied.

Budnik et al. (2012) Intervention - none applied.

Campbell et al. (1999)

Outcomes - shifts in knowledge, attitudes and practices.

Chang and Lamm (2003)

Intervention - none applied.

Chari (2012) Study Type - not a systematic review of studies of effectiveness. Intervention - none applied.

Cifuentes et al. (2010)

Study Type - not a systematic review of studies of effectiveness. Interventions – relevant but their effectiveness was not tested.

da Silva et al. (2012)


Ferris et al. (2008) Study type - not a systematic review as no inclusion criteria used. Intervention - none applied.

Genaidy et al. (2009)

Outcomes - relevant outcomes not measured.

Genaidy et al. (2010)

Outcomes - relevant outcomes not measured.

Grosse et al. (2002) Study type - not a systematic review.

Gunnell et al. (2007) Study type - not a systematic review.

Haby et al. • Interventions that facilitate sustainable development by preventing toxic exposure to chemicals SUPPLEMENTARY MATERIAL

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Jones-Hughes et al. (2013)

Intervention - toxic levels of arsenic are not due to industrial or agricultural processes but are naturally occurring.

Karrari et al. (2012) Study type - not a systematic review. Intervention - none applied.

Korchevskiy (2012) This is just a conference abstract. A full publication could not be found. Thus, cannot be assessed for inclusion.

Li et al. (2013) Study type - not a systematic review (no inclusion criteria). Intervention - none applied.

Lipscomb (2000) Intervention - not aimed at preventing toxic exposure to chemicals but eye injuries in general.

Merler et al. (1997) Study type - not a systematic review (no inclusion criteria). Intervention - not related to prevention of exposure.

Mozaffarian and Rimm (2006)

Intervention - none tested.

Nolan et al. (2012) Study type - systematic review of cases, not effectiveness studies. Intervention - none applied.

Nurmatov et al. (2013)

Study type - protocol for a potentially relevant systematic review. Intervention – none applied.

Panuwet et al. (2012)

Study type - not a systematic review.

Pearson et al. (2014)

Study type - not a systematic review of studies of effectiveness.

Peckham and Awofeso (2014)

Study type - not a systematic review.

Razavi et al. (2013) Intervention - not about prevention of exposure.

Roberts et al. (2003) Study type - not a systematic review.

Schmitt et al. (2007) Intervention – not a focus of the review.

Senanayake and Participants - not humans but crops.


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Mukherji (2014) Outcomes - relevant outcomes not measured.

Soltaninejad and Abdollahi (2009)


Stehle et al. (2011) Participants - not humans but vegetated treatment systems.

Thomson et al. (2009)

Interventions - chemical exposures (radon, lead, allergens) were excluded.

Thomson et al. (2013)

Interventions - chemical exposures (radon, lead, allergens) were excluded.

Timbie et al. (2013) Interventions - primary focus was management of events, not prevention of exposure.

Treasure et al. (2002)

Intervention - promotion of therapeutic exposure through fluoridations (prevention of dental caries), prevention of adverse effects (fluorosis). Note: not due to agricultural or industrial processes.

Yeoh et al. (2008) Meets inclusion criteria but superseded by an update that was conducted in 2012 and is included in this overview.

You et al. (2013) Intervention - none applied.

Young et al. (2004) Study type - not a systematic review.

Zheng et al. (2011) Intervention - none applied.

Zhu et al. (2012) Language - Chinese.


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Table A1b. Economic evaluations excluded at full-text stage (n=4)

Review Reason/s for exclusion

Bierkens et al. (2012)

Study type - not an economic evaluation. Only money value of lost income / productivity calculated.

Grosse et al. (2002)

Study type - not an economic evaluation. Only money value of lost income calculated.

Florax et al. (2005) Study type - not an economic evaluation. Intervention - none evaluated.

Travisi et al. (2006) Study type - not an economic evaluation.

References – excluded studies

Bauer A, Schmitt J, Bennett C, Coenraads P-J, Elsner P, English J, et al. 2010. Interventions for preventing occupational irritant hand dermatitis. Cochrane Database of Systematic Reviews Issue 6; CD004414.

Bierkens J, Buekers J, Van Holderbeke M and Torfs R 2012. Health impact assessment and monetary valuation of IQ loss in pre-school children due to lead exposure through locally produced food. Science of the Total Environment 414; 90-97.

Budnik LT, Kloth S, Velasco-Garrido M and Baur X 2012. Prostate cancer and toxicity from critical use exemptions of methyl bromide: Environmental protection helps protect against human health risks. Environmental Health 11; 5.

Campbell M, Buckeridge D, Dwyer J, Fong S, Mann V, Sanchez-Sweatman O, et al. 1999. Effectiveness of environmental awareness interventions (Report). Hamilton, ON: Effective Public Health Practice Project (EPHPP).

Chang S and Lamm SH 2003. Human health effects of sodium azide exposure: A literature review and analysis. International Journal of Toxicology 22; 175-186.

Chari R. 2012. Modification of lead toxicity by socioeconomic factors and implications for environmental policy. PhD, Johns Hopkins University.

Cifuentes E, Trasande L, Ramirez M and Landrigan PJ 2010. A qualitative analysis of environmental policy and children's health in Mexico. Environmental Health 9; 14.

da Silva TP, Moreira JC and Peres F 2012. Are tick medications pesticides? Implications for health and risk perception for workers in the dairy cattle sector [Portuguese]. Cien Saude Colet 17; 311-325.


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Ferris ITJ, Ortega Garcia JA, Garcia ICJ, Lopez Andreu JA, Ribes Koninckx C and Berbel Tornero O 2008. Risks factors for pediatric malignant liver tumors. [Spanish] Factores de riesgo para los tumores hepaticos malignos pediatricos. Anales de Pediatria 68; 377-384.

Florax RJGM, Travisi CM and Nijkamp P 2005. A Meta-analysis of the Willingness to Pay for Reductions in Pesticide Risk Exposure. European Review of Agricultural Economics 32; 441-467.

Genaidy AM, Sequeira R, Tolaymat T, Kohler J and Rinder M 2009. Evidence-based integrated environmental solutions for secondary lead smelters: Pollution prevention and waste minimization technologies and practices. Science of the Total Environment 407; 3239-3268.

Genaidy AM, Sequeira R, Tolaymat T, Kohler J, Wallace S and Rinder M 2010. Integrating science and business models of sustainability for environmentally-challenging industries such as secondary lead smelters: A systematic review and analysis of findings. Journal of Environmental Management 91; 1872-1882.

Grosse SD, Matte TD, Schwartz J and Jackson RJ 2002. Economic gains resulting from the reduction in children's exposure to lead in the United States. Environmental Health Perspectives 110; 563-569.

Gunnell D, Fernando R, Hewagama M, Priyangika WD, Konradsen F and Eddleston M 2007. The impact of pesticide regulations on suicide in Sri Lanka. International Journal of Epidemiology 36; 1235-1242.

Jones-Hughes T, Peters J, Whear R, Cooper C, Evans H, Depledge M, et al. 2013. Are interventions to reduce the impact of arsenic contamination of groundwater on human health in developing countries effective? A systematic review. Environmental Evidence 2; 11.

Karrari P, Mehrpour O and Abdollahi M 2012. A systematic review on status of lead pollution and toxicity in Iran; Guidance for preventive measures. DARU Journal of Pharmaceutical Sciences 20; 2.

Korchevskiy A 2012. Children's lead exposure in the former soviet union: Principles and methods of determination, regulation and prevention [Conference Abstract]. Epidemiology 1; S353.

Li Z, Ma Z, van der Kuijp TJ, Yuan Z and Huang L 2013. A review of soil heavy metal pollution from mines in China: Pollution and health risk assessment. Science of the Total Environment 468-469; 843-853.

Lipscomb HJ 2000. Effectiveness of interventions to prevent work-related eye injuries. American Journal of Preventive Medicine 18; 27-32.

Merler E, Buiatti E and Vainio H 1997. Surveillance and intervention studies on respiratory cancers in asbestos-exposed workers. Scandinavian Journal of Work, Environment & Health 23; 83-92.

Mozaffarian D and Rimm EB 2006. Fish intake, contaminants, and human health evaluating the risks and the benefits. Journal of the American Medical Association 296; 1885-1899.


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Nolan K, Kamrath J and Levitt J 2012. Lindane toxicity: A comprehensive review of the medical literature. Pediatric Dermatology 29; 141-146.

Nurmatov UB, Tagieva N, Semple S, Devereux G and Sheikh A 2013. Volatile organic compounds and risk of asthma and allergy: A systematic review and meta-analysis of observational and interventional studies. Primary Care Respiratory Journal 22; PS9-PS15.

Panuwet P, Siriwong W, Prapamontol T, Ryan PB, Fiedler N, Robson MG, et al. 2012. Agricultural pesticide management in Thailand: Status and population health risk. Environmental Science and Policy 17; 72-81.

Pearson M, Zwi AB, Rouse AK, Fernando R, Buckley NA and McDuie-Ra D 2014. Taking stock—What is known about suicide in Sri Lanka: A systematic review of diverse literature. Crisis: The Journal of Crisis Intervention and Suicide Prevention 35; 90-101.

Peckham S and Awofeso N 2014. Water fluoridation: A critical review of the physiological effects of ingested fluoride as a public health intervention. The Scientific World Journal 2014.

Razavi SM, Salamati P, Harandi AA and Ghanei M 2013. Prevention and treatment of respiratory consequences induced by sulfur mustard in Iranian casualties. International Journal of Preventive Medicine 4; 383-389.

Roberts DM, Karunarathna A, Buckley NA, Manuweera G, Sheriff MH and Eddleston M 2003. Influence of pesticide regulation on acute poisoning deaths in Sri Lanka. Bulletin of The World Health Organization 81; 789-798.

Schmitt NM, Schmitt J, Kouimintzis DJ and Kirch W 2007. Health risks in tobacco farm workers - A review of the literature. Journal of Public Health 15; 255-264.

Senanayake N and Mukherji A 2014. Irrigating with arsenic contaminated groundwater in West Bengal and Bangladesh: A review of interventions for mitigating adverse health and crop outcomes. Agricultural Water Management 135; 90-99.

Soltaninejad K and Abdollahi M 2009. Current opinion on the science of organophosphate pesticides and toxic stress: A systematic review. Medical Science Monitor 15; RA75-RA90.

Stehle S, Elsaesser D, Gregoire C, Imfeld G, Niehaus E, Passeport E, et al. 2011. Pesticide Risk Mitigation by Vegetated Treatment Systems: A Meta-Analysis. Journal of Environmental Quality 40; 1068-1080.

Thomson H, Thomas S, Sellstrom E and Petticrew M 2009. The health impacts of housing improvement: a systematic review of intervention studies from 1887 to 2007. American Journal of Public Health 99 Suppl 3; S681-S692.

Thomson H, Thomas S, Sellstrom E and Petticrew M 2013. Housing improvements for health and associated socio-economic outcomes. Cochrane Database of Systematic Reviews Issue 2; CD008657.

Timbie JW, Ringel JS, Fox DS, Pillemer F, Waxman DA, Moore M, et al. 2013. Systematic review of strategies to manage and allocate scarce resources during mass casualty events. Annals of Emergency Medicine 61; 677-689.

Travisi CM, Nijkamp P and Vindigni G 2006. Pesticide Risk Valuation in Empirical Economics: A Comparative Approach. Ecological Economics 56; 455-474.


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Treasure ET, Chestnutt IG, Whiting P, McDonagh M, Wilson P and Kleijnen J 2002. The York review--a systematic review of public water fluoridation: a commentary. British Dental Journal 192; 495-497.

Yeoh B, Woolfenden S, Wheeler D, Alperstein G and Lanphear B 2008. Household interventions for prevention of domestic lead exposure in children. Cochrane Database of Systematic Reviews Issue 2; CD006047.

You T, Lv J and Zhou L 2013. PON1 Q192R and L55M polymorphisms and organophosphate toxicity risk: a meta-analysis. DNA and Cell Biology 32; 252-259.

Young S, Balluz L and Malilay J 2004. Natural and technologic hazardous material releases during and after natural disasters: A review. Science of the Total Environment 322; 3-20.

Zheng W, Wang X, Yu H, Tao X, Zhou Y and Qu W 2011. Global trends and diversity in pentachlorophenol levels in the environment and in humans: A meta-analysis. Environmental Science and Technology 45; 4668-4675.

Zhu H, Lei X, Zhang F and Wang Y 2012. Risk factor and population attributable risk of children leukemia in China: A meta-analysis. Chinese Journal of Evidence-Based Medicine 12; 1246-1250.


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SUPPLEMENTARY FILE 2. Characteristics of included systematic reviews

Note: Two tables are included in this file in order to show all relevant details – Tables A2a and A2b.

Table A2a. Characteristics of included systematic reviews – sorted alphabetically

Systematic review

Objectives Inclusion criteria – PICOS (Participants, Interventions, Comparisons, Outcomes, Study Types); Years of publication of papers

Date of search; number of papers/studies included; AMSTAR score

Haynes et al. (2002)

The purpose of this study was to use meta-analysis to determine whether low-cost strategies (defined as < $2,500 per housing unit or family) aimed at controlling lead-contaminated dust effectively prevent childhood lead exposure, as measured by children’s blood lead concentrations.

P – Children I – Low-cost dust control interventions to prevent children’s exposure to residential lead, i.e. < $US 2,500 C – Any control group O – Blood lead concentration S – RCTs Years: NS Trials conducted in a community with a continual lead emission source were excluded.

NS 4 randomized controlled trials AMSTAR – 6

Jacobs et al. (2010)

The goal of this systematic review was to assess the effectiveness of housing interventions on improving health in four broad intervention areas: • Interior biological agents (toxins) • Interior chemical agents (toxics) • Structural deficiency (injury) • Community-level housing

Note: only the methods and results of the interior chemical agents (toxics) are included here.

P – NS (mostly based on human studies) I – Interior chemical agents (toxics) interventions C – NS O – Clinical evidence (or other health data such as self-reported health) and/or environmental measurements S – NS; published in English Years: 1990 to December 2007

December 2007 NS AMSTAR – 0

James et al. What is the effectiveness of local P – General public or high risk December 1998


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Systematic review



(1999) public health teams in preventing morbidity and mortality and providing timely and appropriate interventions in organized emergency disaster response to acute non-natural environmental hazards?

subpopulations. I – The intervention: (i) is in relation to an acute non-natural environmental hazard or incident with potential to affect the general public or high risk sub-populations; (ii) involves organized emergency disaster response which may or may not include a public health team as part of the response; (iii) aimed at protecting the general public or high risk sub-populations. C – NS O – Outcomes of interest include mortality, morbidity, risk perception and psychosocial impact on the general public. S – Examined the effectiveness of the intervention. Evaluated the intervention or any of its components. (This included, risk communications, multi-emergency response teams with a variety of disciplines or services, and may have included particular professional involvement such as pharmacists); Years: 1964 – December 1998

0 studies AMSTAR – 1

Keifer (2000) The purpose of this review is to describe the effectiveness of interventions designed to prevent pesticide overexposure among working populations. Our review was aimed at identifying any workplace intervention that addressed reducing pesticide

P – All ages and both genders. Subjects could be workers who were mixers, loaders, sprayers; general farm workers; or the general population. I – Interventions considered included pesticide safety training, applicator training and licensure, field re-entry restrictions, use of

NS 17 papers AMSTAR – 3


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Systematic review



exposure to a working population, although any articles that identified interventions aimed at a reduction of poisonings or exposure in any population were considered.

personal protective equipment (PPE), use of isolation techniques such as closed tractor cabs, pesticide handling (mixing, loading or storage) techniques or procedures, or bio-monitoring programs. C – Study identified a control population or control methods O – Biological monitoring measures or personal exposure monitoring indicating a reduction of pesticide exposure, observed increased use of PPE, reduction in lost workdays, and where possible, evidence of changes in pesticide poisoning rates s as identified by registries and population surveys. S – Both epidemiologic designs of interventions and field trials of protective equipment were included if methods were clearly described and data were presented that objectively measured exposure or a surrogate for exposure (including cholinesterase (AChE); published in English Years: NS

Lucas et al. (2011)

The aim of the systematic review was to evaluate the impact of dissemination of water quality information about a) chemical contamination and b) microbial contamination on health outcomes, knowledge of risk, source switching, ‘point-of-use’ water treatment,

P – Populations living in areas where chemical or microbiological contamination of drinking water posed a known health risk I – Drinking water contamination (chemical and/or microbiological) was tested and results disseminated to individuals or communities. Testing could take place at any local site (e.g. private well or tap, shared well

January 2010 14 papers / 6 studies AMSTAR – 9


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Systematic review



source treatment, and water quality improvements.

or tap, community source). C – Included alternate or no-treatment control groups O – Changes in health, water source, water treatment, water quality, and knowledge of contaminant risk. S – RCTs, Quasi-RCTs, Cohort Studies, Time series, and Controlled (including non-equivalent comparison groups) before and after studies Years: NS to January 2010

Lum et al. (2006)

We sought the most comprehensive review possible not only to learn about what we know “works” in terms of reducing terrorism, but also to learn about the state of terrorism research more generally to guide future evaluation research agendas.

P – NS I – Any program generally designed to prevent, detect, manage, or respond to terrorism events and related incidents. Terrorism was defined broadly as politically motivated violence as normally or officially defined. However, any study in which the author(s) referred to the program or outcome as terrorism or terrorism-related was also included, even if not normally or traditionally considered as terrorism or even if their perception of terrorism contradicted official definitions. C – NS O – Events related to terrorism. These “events” could be incidents of terrorism, the number of groups who engaged in the use of terrorism, or the frequency of other activities related to terrorist groups. Also included were: reduction of the public’s fear of

December 2004 7 papers/studies AMSTAR – 8


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Systematic review



terrorism or their feelings of safety from it, the increased ability to respond to certain events, the reduction in the level of risk of an event occurring, or the ability to detect mechanisms of terrorism (for example, the ability to detect anthrax spores in mail). Outcomes measured might include general manifestations (i.e., “terrorism”) as well as specific groupings (i.e. “skyjackings”, “hostage-taking”, “casualty” or “non-casualty”). Outcomes that were too far removed from measurable outcomes with regard to terrorism were not included in the final review, e.g. stock market performance. S – Any type of evaluation at least of moderately strong methodological design:

evaluated two or more units of analysis, comparing some with and without the counter-terrorism intervention;

made some attempt to provide for controls within a statistical analysis;

conducted an interrupted time series or intervention analysis to indicate some temporal ordering of effects

And was published in English; medically-oriented evaluations were excluded, e.g. vaccination for smallpox. Years: Up to December 2004

Mann et al. (2005)

To examine evidence for the effectiveness of specific suicide-preventive interventions and to make

P – NS I – Suicide prevention programs, e.g. education and awareness programs for the

June 2005 93 papers / studies:


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Systematic review



recommendations for future prevention programs and research.

general public and professionals; screening methods for high-risk persons; treatment of psychiatric disorders; restricting access to lethal means; and media reporting of suicide. C – NS O – Completed and attempted suicide and suicidal ideation; or, where applicable, intermediate outcomes, including help-seeking behavior, identification of at-risk individuals, entry into treatment, and antidepressant prescription rates. S – Systematic reviews and meta-analyses; quantitative studies, either randomized controlled trials or cohort studies; and ecological, or population-based studies Years: 1966 to June 2005

10 systematic reviews and meta-analyses, 18 RCTs, 24 cohort studies, 41 ecological or population based studies. AMSTAR – 2

Rabinowitz et al. (2008)

The goal of this systematic review was to identify evidence that animals could serve as sentinels of an attack with a chemical terrorism agent.

P – Animals and/or humans I – Animals as sentinels (early warning) of presence of chemical agents C – NS O – Susceptibility of animals to a chemical agent; latency period (time from exposure to onset of adverse effect) for the animal; chemical exposure risk; evidence of early warning S – NS (Methodologies used by included studies: Level 1 – experimental studies, cohort studies; Level 2 – case-control studies, ecologic (aggregate) and cross-sectional surveys; Level 3 – professional consensus

NS 42 papers AMSTAR – 1


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Systematic review



statements, textbooks, and descriptive case reports) Years: NS

Rautiainen et al. (2008); Lehtola et al. (2008)

This review aims to determine the effectiveness of interventions to prevent occupational injuries among workers in the agricultural industry compared to no interventions or to alternative interventions.

P – Agricultural industry workers in establishments primarily engaged in growing crops and animal production. I – Interventions deliberately applied to decrease the rate, or severity of, injuries were included. The interventions involved engineering/technology, education/behavior change (includes incentives), legislation/enforcement, or multifaceted programs. The interventions were administered at the national, regional, organizational, community or individual level. C – NS O – Fatal or non-fatal occupational injuries. S – RCTs, cluster-RCTs, prospective cohort studies with a concurrent control group, and interrupted time series studies Years: Up to June 2006

June 2006 8 studies – 3 RCTs, 2 cluster-RCTs, 3 interrupted time series AMSTAR – 8

Saegert et al. (2003)

We sought to characterize and to evaluate the success of current public health interventions related to housing.

P – Human I – Housing interventions, defined as intentional, systematic efforts to improve residential conditions, either directly or indirectly, through one or more of the following measures: rehousing (moving to new housing); changes in physical infrastructure; changes in indoor

December 2001 72 papers / 69 interventions AMSTAR – 1


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Systematic review



equipment or furniture; changes in participants’ knowledge or behavior; changes in community norms or collective behavior; changes in housing policy and regulatory practices; and changes in health practitioners’ behavior related to housing effects on health. C – NS O – Health S – Evaluation; conducted in the USA; published in peer-reviewed journals. Years: January 1990 to December 2001

Sarchiapone et al. (2011)

In the present review we aimed to summarize methods of suicide attempts and studies addressing and evaluating the possibility to restrict access to such methods as preventive strategies for suicide attempt.

P – Human I – Restriction of access to means of suicide. Other preventive strategies for suicidal behavior, such as educational programs and treatment interventions were excluded. C – NS O – Suicide attempt S – NS; Study addressed (1) suicide means and/or (2) restriction of access to such means; written in English. Years: NS

NS NS AMSTAR – 0

Smith-Spangler et al. (2012)

To review evidence comparing the health (nutrition, safety) effects of organic and conventional foods.

P – Human; foods grown conventionally or organically. I – Consumption of or exposure to foodstuffs produced by organic farming methods. C – Conventionally produced foodstuffs. O – NS, though reported health outcomes for

May 2009 17 studies (14 unique populations) in humans and 223 studies of nutrient and contaminant levels in


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Systematic review



the human studies and nutrient and contaminant levels for the food studies. S – Peer-reviewed studies of comparisons of organically and conventionally grown food or of populations consuming these foods; written in English. Years: 1966 to May 2009

foods AMSTAR – 7

Yeoh et al. (2012)

To determine the effectiveness of household interventions in preventing or reducing lead exposure in children as measured by reductions in blood lead levels and/or improvements in cognitive development.

P – Children I – Household educational and/or environmental interventions to prevent lead exposure. Interventions involving nutritional supplementation were excluded. Mode of delivery may be by health professionals, paraprofessionals or via written media. C – NS O – Cognitive and neurobehavioral outcomes in children; blood lead levels; household dust measures. S – RCTs or quasi-randomized controlled trials; any language. Years: Up to January 2012

20 January 2012 19 papers / 14 studies – 13 RCTs, 1 quasi-RCT AMSTAR – 10

NS – not specified; RCTs - Randomized controlled trials; USA – United States of America;


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Table A2b. Characteristics of included systematic reviews – sorted alphabetically

Systematic review

Details of interventions studied (number of studies)

Country / Region of studies (number)

Link with sustainable development / dimensions of integrated framework

Summary of findings

Haynes et al. (2002)

Education combined with cleaning equipment or supplies (2) Dust control performed by cleaning professionals (2)

NS

Elevated blood lead concentrations in children can impact on cognition (IQ) and thus future productivity (Econ) and on health, development and behavior (Social). There can also be impacts on violence (P&S). Changes to the levels of lead in the house (e.g. in paint) can impact on the indoor air (Env).

We conclude that although low-cost, interior lead hazard control was associated with 50% or greater reduction in the proportion of children who had blood lead concentrations exceeding 15 µg/dL (6% versus 14% (OR, 0.40; 95% CI, 0.21–0.80)) and ≥ 20 µg/dL (2% versus 6% (OR, 0.29; 95% CI, 0.10–0.85)), there was no substantial effect on mean blood lead concentration or on the proportion of children who had blood lead concentrations ≥ 10 µg/dL (29% versus 32% (OR, 0.85; 95% CI, 0.56–1.3)).

Jacobs et al. (2010)

Sufficient evidence: • active radon air

mitigation (7) • integrated pest

management (IPM) (as pesticide exposure reduction) (1)

• smoke-free policies (6) • residential lead hazard

control (3 reviews) Promising interventions: • radon in drinking water

NS Mostly USA?

Exposure to indoor chemical agents has been associated with neurotoxicity and developmental disorders, asthma and other respiratory illnesses, and cancer (Social, Econ). Indoor emissions for burning solid waste are also linked to the

Four of the 14 interventions reviewed had sufficient evidence to demonstrate their effectiveness and are ready for implementation: radon air mitigation by using active soil depressurization systems, integrated pest management to reduce exposures to pesticides, smoke-free home policies making indoor areas smoke-free (i.e. no smoking allowed anywhere at any time), and residential lead hazard control. Four interventions needed more field evaluation, 3 needed formative research, and 3 either had


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Systematic review




Summary of findings

mitigation (1) • particulate air cleaners

(3) • particulate control by

envelope sealing (2) • attached garage

sealing (2) Formative research needed: • passive radon air

mitigation • residential ventilation • reductions of volatile

organic compounds (VOCs)

No evidence/ineffective interventions: • air cleaners using or

releasing ozone • portable air cleaners to

reduce SHS or gases • single professional

cleaning to control lead exposure

environment, as black carbon has a warming effect on climate (Env).

no sufficient evidence of effectiveness or had evidence the interventions were ineffective. This evidence review shows that housing improvements are likely to help reduce radon-induced lung cancer, cardiovascular mortality related to secondhand smoke, and neurological effects from exposure to pesticides and lead paint.

James et al. (1999)

None identified Not applicable

Acute non-natural environmental hazards or incidents impact on peace & security (P&S) and

There was no high quality evidence to use in decision-making about how Public Health Units could best be staffed, or how toxicological and other relevant resources should best be deployed to assist Public


19

Systematic review




Summary of findings

health (Social). They also disturb the production of goods, and require additional resources for the response (Econ).

Health Units in discharging the responsibilities of the Health Hazard Investigation Mandatory program. Although a small number of studies describing health impacts or assessing risk were identified in the published literature, there were no high quality evaluations of interventions by public health teams identified in the international search undertaken.

Note: Here, high quality evaluation refers to the incorporation of controlled approaches or time-series methods.

Keifer (2000) Use of personal protective equipment (PPE) such as gloves, coveralls, shoes, and facial scarves (13) Changes to pesticide handling: • Mixing – water soluble

packets, closed pumping systems (4)

Pesticide application methods: • Closed cabs (1) • Hand wands (1) • Ventilation during

application (2) Worker education (1)

NS for all studies. Examples cited include: United Arab Emirates, Denmark, USA, Canada for PPE; and USA, Nicaragua for pesticide

Pesticide use can impact on environmental sustainability (Env); on the community’s, and particularly on children’s and workers’ health (Social); and potentially workplace productivity if the worker suffers health problems (Econ).

Results were mixed regarding the effectiveness of PPE in reducing workers’ exposure to pesticides though generally showed reduced exposure.

Unidirectional ventilation reduced worker’s exposure compared to no ventilation and was more effective than multidirectional ventilation.

For mixing - water soluble packets offered the greatest protection as compared with open pouring of liquid concentrate or open dumping of wettable powder or closed system pumping. Closed pumping systems resulted in lower exposure as compared with open pouring or pouring of wettable powder.


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Systematic review




Summary of findings

Biological monitoring programs (1) Pesticide substitutions (0) Legislation (0)

Note: the number of studies sum to more than 17 as some studies tested multiple strategies. Results for multi-strategy interventions were not specifically discussed.

handling and application methods;

The most effective method for worker protection during application involved ground boom sprayers with enclosed cabs. Hand wand application was associated with highest exposure levels.

Biological monitoring can identify workers at risk and result in removal of the worker. However, it doesn’t necessarily result in reduction in exposure to pesticides as workers can be re-exposed.

Lucas et al. (2011)

Drinking water tested for contamination and results disseminated to households. Contaminants tested include: • Arsenic (4) • Feces (2) Note: all studies required behavior change at the individual rather than community level.

Arsenic: Bangladesh (4) Feces: India (1) Kenya (1)

Contamination of drinking water is a serious human health hazard (Social), and impacts on health security and human rights (P&S).

Despite the publication of some large cohort studies and some encouraging results the evidence base to support dissemination of contamination data to improve water management is currently equivocal. The strongest evidence was for source switching in response to arsenic contamination information, with 4 studies reporting higher rates of switching (26–52%) in households previously drinking from contaminated wells (3 at statistically significant levels). A pooled risk difference was calculated for 2 studies of arsenic contamination (RD=0.43 [CI0.4.0–0.46] 6–12 months post intervention) suggesting 43% more of those with unsafe wells switched source compared to those with safe wells. Strength of evidence


21

Systematic review




Summary of findings

is low since the comparison is between non-equivalent groups. One study of arsenic contamination measured health effects. They reported a significant reduction of urinary arsenic among those using unsafe wells at baseline of 109 vs 6.2 m/L, Standardized Mean Difference of 20.42 [CI20.45,20.35] between groups, favoring those who had been informed that their wells were unsafe. These results were unadjusted for baseline differences between groups, risk of bias in study judged to be low/moderate. Two studies concerning fecal contamination reported non-significant increases in point-of-use water treatment.

Lum et al. (2006)

Interventions which: • Increased detection at

airports, including installing metal detectors and increasing security screening more generally.

• Increased protection, including those which fortified embassies or protected diplomats.

• Increased the length and/or severity of

Israel (1), Spain (1), USA (1), NS or multiple (4)

Terrorism impacts on Peace & Security (P&S) and can lead to death and injury (Social).

There is almost a complete absence of high quality scientific evaluation evidence on counter-terrorism strategies. What evidence there is does not indicate consistently positive results – some counter-terrorism interventions show no evidence of reducing terrorism and may even increase the likelihood of terrorism and terrorism-related harm. No studies looked specifically at chemical terrorism. The available evidence suggests: • The use of metal detectors in airports

reduces hijackings; however, there may also be a substitution or displacement effect of airport security on other types of


22

Systematic review




Summary of findings

punishment for those apprehended and convicted of terrorism.

• Represented United Nations Resolutions against terrorism.

• Military interventions and/or retaliations, specifically, the Israeli retaliation attacks on the PLO and Lebanon in the 1970s and 1980s and the United States attack on Libya in 1986.

• Changes in political governance, such as having certain political ideologies in power or the end of the cold war (and reduction in totalitarian states).

terrorism (e.g. assassinations, bombings, hostage taking, death and wounded events).

• Fortifying embassies and efforts to protect diplomats do not appear effective in reducing terrorist attacks on these targets.

• Increasing the severity of punishment for hijackers does not appear to have a statistically discernible effect on reducing skyjacking incidents although there is very limited research conducted in this area.

• UN resolutions, without the implementation of metal detectors, have not been shown to reduce terrorism.

• Retaliatory attacks (for example, the U.S. attack on Libya in 1986 or attacks by Israel on the PLO) have significantly increased the number of terrorist attacks in the short run, particular against the United States, the United Kingdom, and Israel.

• The existence of intolerant political parties (to terrorism) and the end of the Cold War could increase terrorism events although the findings in this review were uncertain.

Mann et al. (2005)

• Education and awareness for the general public and for professionals

• Screening tools for at-

Restricting access to pesticides: Samoa (1),

Restricting access to toxic chemicals can prevent suicide (Social) and improve health security (P&S).

In regards to restricting access to lethal means: Suicide attempts using highly lethal means, such as firearms in US men, or pesticides in rural China, India, and Sri Lanka, result in


23

Systematic review




Summary of findings

risk individuals • Treatment of

psychiatric disorders • Restricting access to

lethal means (30 ecological studies, 2 on pesticides)

• Responsible media reporting of suicide

Finland (1)

higher rates of death. Suicides by such methods have decreased after firearm control legislation (6 studies), restrictions on pesticides (2 studies), detoxification of domestic gas (6 studies), restrictions on the prescription and sale of barbiturates (6 studies), changing the packaging of analgesics to blister packets (1 study), mandatory use of catalytic converters in motor vehicles (4 studies), construction of barriers at jumping sites (1 study), and the use of new lower toxicity antidepressants (2 studies). Substitution of method may obscure a change in overall suicide rates, as has been observed for domestic gas detoxification among men in the United Kingdom (1 study), in Germany (1 study), and in the United States (1 study), and for banning the pesticide parathion in Finland (1 study).

Rabinowitz et al. (2008)

Animals as sentinels of chemical agents (42)

NS Early warning of exposure to chemical agents could potentially prevent human exposure, thus having health impacts (Social). It would also result in greater security (P&S).

Currently, there is insufficient evidence for routine use of animals as sentinels for airborne chemical warfare agents. Only six of the 42 articles provided any evidence that supported animals as possible sentinels of an airborne chemical terrorist attack. The quality of the evidence was insufficient to draw conclusions.


24

Systematic review




Summary of findings

Rautiainen et al. (2008); Lehtola et al. (2008)

• Engineering/technology (0)

• Education/behavior change, including incentives (6)

• Legislation/enforcement (2 interrupted time series): o Endosulfan ban (1) o Roll-over protective

structures and safety cabs in tractors (1)

• Multi-faceted interventions using more than one basic approach (0).

USA (3), Finland (2), Denmark (1) Sri Lanka (1) Sweden (1)

Legislation to ban or restrict access to pesticides and other chemicals could have positive effects on environmental sustainability (Env); on the health of workers, their families and agricultural communities (Social); and potentially family income of the worker if they die as a result of their work (Econ). It may also improve health security by decreasing the availability of the toxin in the food chain, and by eliminating transboundary transportation of the chemicals (P&S).

The selected studies provided no evidence that educational interventions are effective in decreasing injury rates among agricultural workers. Financial incentives could reduce injury rates. Legislation to ban pesticides could be effective. Legislation expanding the use of safety devices (ROPS) on new tractors was associated with a decrease in fatal injuries. For legislation to ban pesticides: One interrupted time series study that evaluated the effect of legislation to ban Endosulfan pesticide on fatal pesticide poisonings increased the level of poisonings immediately after the introduction with an effect size of 2.20 (95% CI 0.97 to 3.43) but led to decrease in the trend of poisonings over time with an effect size of -2.15 (95% CI -2.64 to -1.66). The study did not report whether the deaths were intentional (suicide) or unintentional or whether they were work-related.

Saegert et al. (2003)

• Environmental improvements (22)

• Education (23) • Both environmental

improvements and

USA (72) Housing interventions that focus on prevention of exposure of children to lead can impact on

No findings were provided by types of intervention and exposure, e.g. environmental interventions for lead.


25

Systematic review




Summary of findings

education (25) • Other (2) Note: Interventions were predominately aimed at dwelling unit or participant-level change, or both. Only 5 interventions were aimed at communitywide change.

cognition (IQ) and thus future productivity (Econ) and on health, development and behavior (Social). There can also be impacts on violence (P&S). Changes to the levels of lead in the house (e.g. in paint) can impact on the indoor air (Env).

Sarchiapone et al. (2011)

• Detoxification of toxic domestic gas

• Catalytic converters in motor vehicles – controls on emissions

• Firearms – legal restrictions

• Pesticides – legal restrictions

• Barbituates – restrictions on prescription

• Paracetamol – legislation limiting pack size

• Safety barriers at jump sites

NS Restricting access to toxic chemicals can prevent suicide (Social) and improve health security (P&S).

In many countries, restrictions of access to common means of suicide has lead to lower overall suicide rates, particularly regarding suicide by firearms in USA, detoxification of domestic and motor vehicle gas in England and other countries, toxic pesticides in rural areas, barriers at jumping sites and hanging, by introducing “safe rooms” in prisons and hospitals. Restriction to means of suicide may be particularly effective in contexts where the method is popular, highly lethal, widely available, and/or not easily substituted by other similar methods.


26

Systematic review




Summary of findings

• “Safe rooms” in institutional settings to prevent hanging

• Restrictions on media reporting of suicide

Note: the methods for restricting access were not always clear.

Smith-Spangler et al. (2012)

Participants consumed: A predominately organic diet (4); A limited organic diet (2); Only certain organic foods – apples (2), carrots (1), tomatoes (1), juice and fresh produce (1) or meat or dairy products (2).

Human studies: USA (2), Europe (11), USA & Europe (1)

Organic farming has environmental (Env) and possibly health benefits (Social). It can also bring economic benefits to producers (Econ). It is more labor intensive (more job places), and may also decrease food insecurity (P&S).

The published literature lacks strong evidence that organic foods are significantly more nutritious or healthier than conventional foods. However, organic produce may reduce exposure to pesticide residues. Conventional produce has a 30% higher risk for pesticide contamination than organic produce (risk difference, 30% [CI, –37% to –23%]). Organic chicken and pork may reduce exposure to antibiotic-resistant bacteria.

Yeoh et al. (2012)

• Educational interventions: o Alone (3) o With supply of

cleaning products (2)

• Environmental (household) interventions:

USA (13), Australia (1)

High blood lead concentrations in children can impact on cognition (IQ) and thus future productivity (Econ) and on health, development and behavior (Social). There can also be

Based on current knowledge, household educational or dust control interventions are ineffective in reducing blood lead levels in children as a population health measure. There is currently insufficient evidence to draw conclusions about the effectiveness of soil abatement or combination interventions. The impact on cognitive or neurobehavioral outcomes was not measured in any of the


27

Systematic review




Summary of findings

o dust control (specialized cleaning, repairs, maintenance) (3)

o soil abatement (removal and replacement) (2)

o painting and temporary containment of lead hazards (0)

• Combination – educational, dust control and hazard reduction (4)

impacts on violence (P&S). Changes to the levels of lead in the house (e.g. in paint) can impact on the indoor air (Env).

studies. Educational interventions were not effective in reducing blood lead levels (continuous: mean difference (MD) 0.02, 95%CI -0.09 to 0.12; dichotomous ≥10µg/dL (≥0.48 µmol/L): RR 1.02, 95%CI 0.79 to 1.30; dichotomous ≥15µg/dL (≥0.72 µmol/L): RR 0.60, 95% CI 0.33 to 1.09. Meta-analysis for the dust control subgroup also found no evidence of effectiveness (continuous: MD - 0.15, 95% CI -0.42 to 0.11; dichotomous ≥ 10µg/dL (≥ 0.48 µmol/L): RR 0.93, 95% CI 0.73 to 1.18; dichotomous ≥ 15µg/dL (≥ 0.72 µmol/L): RR 0.86, 95%CI 0.35 to 2.07). The studies using soil abatement (removal and replacement) and combination intervention groups were not able to be meta-analyzed due to substantial differences between studies.

Econ – Economic; Env – Environment; NS – not specified; P&S – Peace & Security; CI – Confidence Interval; IQ – Intelligence Quotient; OR – Odds Ratio; RR – Relative Risk; USA – United States of America.


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SUPPLEMENTARY FILE 3. Characteristics of included economic evaluations

Note: Two tables are included in this file in order to show all relevant details – Tables A3a and A3b.

Table A3a. Characteristics of included economic evaluations – methods & results

Economic evaluation

Intervention, Source of effectiveness data, & Setting

Methods – Population, Comparator, Outcomes, Costs included,

Methods – Type of study, Model, Reference Year, Perspective, Time horizon, Discounting, Funding source

Result, incremental cost-effectiveness ratio

Brown (2002)

Intervention: Strict enforcement strategy for prevention of childhood lead poisoning housing policies.

Source of effectiveness data: Retrospective cohort study comparing blood lead levels in children living in houses with strict versus limited enforcement addresses (Brown et al. 2001)*.

Setting: 2 adjacent urban areas in northeastern USA.

Population – Children who were living in houses that had recorded a previous case of a lead-poisoned child.

Comparator – Limited enforcement strategy for prevention of childhood lead poisoning housing policies.

Benefits – Probability of identifying one child with an elevated blood lead concentration (≥10µg/dL).

Costs – 1) Short-term medical costs (including chelation and monitoring) and special education costs associated with BPb ≥ 10 µg/dL in 1 or more additional children identified subsequent to the initial case of lead poisoning; 2) the long-term costs of decreased employment and lower occupational status

Type of study – Cost-effectiveness analysis (cost-benefit)

Model – Decision tree model

Ref. Year – 2001 for costs

Perspective – Societal

Time horizon – 10 years

Discounting – 3% to 5% on costs

Funding source – supported in part by John and Virginia Taplin, and by the Maternal and Child Health Bureau.

Strict enforcement prevented additional cases, resulting in $US 45,360 savings from decreased medical and education costs and increased productivity for protected children. The intervention was dominant (saved money and resulted in higher efficacy (lower probability of identifying children with an elevated blood lead level)).


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Economic evaluation





associated with the loss of IQ points as a result of lead exposure; and 3) intervention costs, including the cost of inspection, relocation (food and housing) and lead hazard abatement.

Macauley et al. (2001); Macauley et al. (2003)

Intervention: Different policy options for computer monitor disposal:

a) Ban all disposal(incineration and landfill); b)Ban all disposal andsubsidize recycling by $10per monitor; c) Curbsiderecycling offered; d)Subsidize recycling toachieve 10% recycling rate;e) Subsidize recycling toachieve 23% recycling rate;f) Ban incineration only; g)Curbside recycling with banon all disposal.

These policy options are designed to reduce disposal through the incineration or landfilling of computer monitors, which results in air emissions of lead released

Population – Three sample areas: the Washington, D.C., metropolitan area, the Midwest region, and the Northeast region (USA).

Comparator – The base case is the end-of-life allocation option by consumer type, assuming that consumers pick the lowest private cost option among the choices available to them.

Benefits – Health effects avoided, measured as dollar estimates of medical costs, lost future earnings due to reduction in IQ, and the cost of educating children with special needs.

Costs – Private costs of computer monitor disposal for

Type of study – Cost-benefit analysis

Model – Computer Monitor Policy Simulation (COMPS) model

Ref. Year – 1998

Perspective – NS

Time horizon – NS

Discounting – NS

Funding source – Economic and Social Research Institute of Japan.

For the stock of monitors disposed of in the United States in 1998, we find that policies restricting or banning some popular disposal options would increase disposal costs from about $US 1 per monitor to between $US 3 and $US 20 per monitor. Policies to promote a modest amount of recycling of monitor parts, including lead, can be less expensive. In all cases, however, the costs of the policies exceed the value of the avoided health effects of CRT disposal.


30

Economic evaluation





from the cathode ray tubes (CRTs) in the computer monitor.

Source of effectiveness data: USA data from 1998 on CRT sales and survey data is used to estimate how monitors are retired. Effectiveness of policy options assume that consumers pick the lowest private cost option among the choices available to them.

Setting: USA.

the different options, including storage, transportation (residential household travel and time), and recycling process.

USA – United States of America; * Brown MJ, Gardner J, Sargent JD, Swartz K, Hu H and Timperi R 2001. The effectiveness of housing policies in reducing children's

lead exposure. American Journal of Public Health 91; 621-624.


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Table A3b. Characteristics of included economic evaluations – commentary

Economic evaluation


Strengths & Limitations Critical success factors / Comments

Brown (2002)

Elevated blood lead concentrations in children can impact on cognition (IQ) and thus future productivity (Econ) and on health, development and behavior (Social). There can also be impacts on violence (P&S). Changes to the levels of lead in the house (e.g. in paint) can impact on the indoor air (Env).

The most appropriate perspective (i.e. society) was adopted in the study. Extensive sensitivity analyses were carried out, which enhanced the external validity of the analysis. The model was robust to changing estimates of follow up, housing repairs, relocation, and increases in lead levels over baseline. The results of this analysis are not generalizable to areas where lead paint and lead paint contaminated house dust are not the dominant pathway for childhood lead exposure. The use of forgone earnings to estimate the indirect cost of illness is a subject of some controversy. Predictions about future earnings may either over- or underestimate actual earnings.

Because abatement is a one-time cost, but children continue to be exposed, decreasing the follow up period reduces the cost savings that result from strict environmental enforcement. Strict environmental enforcement must effectively prevent recurrent cases of elevated blood lead for >3 years before it becomes the dominant strategy.

Macauley et al. (2001); Macauley et al. (2003)

Lead air emissions lead to higher blood lead concentrations. In children these can impact on cognition (IQ) and thus future productivity (Econ) and on health, development and behavior (Social). Health in adults is also affected. There can also be impacts on violence (P&S). For the environment, there is risk

The COMPS model used for this analysis has several limitations. Most of these limitations are due to extremely limited data, including for CRT purchases, imports, and exports; and end of life CRT disposal choices. Our analysis also is limited because we don’t consider CRTs found in televisions or the role of flat panel displays as substitutes for traditional computer monitors. Finally, because our analysis is focused on CRTs, we don’t track what happens to the other components of computer monitors, such as the plastic housing or cover. For example, incineration of the plastic housing can release

The significant differences among the costs of our policy scenarios are explained by differences in the goals of the policies—for example, banning incineration, encouraging recycling generally, or encouraging recycling to meet a specified recycling goal. A recycling subsidy is a more cost-effective way to increase monitor recycling than a disposal ban. However, a recycling subsidy reduces storage more than it reduces incineration or landfilling, causing the


32

Economic evaluation


Strengths & Limitations Critical success factors / Comments

of contamination of soil and water by disposal in uncontrolled solid waste disposal sites, landfills or recycling areas (Env).

dioxins according to some researchers (although this conclusion is controversial), and we do not include this effect in our environmental damages module. Several important aspects of the cost-benefit analysis are not clearly specified, including discount rate, reference year and time horizon.

environmental benefits from reduced incineration to be small. If the goal of a policy is to reduce the potential health damages associated with incineration of lead, banning incineration of CRTs is much more cost-effective than banning all forms of disposal. A ban on landfilling and incineration of used monitors results in an average disposal cost of almost $20 per monitor while a ban on incineration results in an average cost of just over $3 per monitor.

CRT – cathode ray tube; Econ – Economic; Env – Environment; NS – not specified; P&S – Peace & Security; IQ – Intelligence Quotient.

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