Basic terms of environmental health (hygiene in Central European context) and introduction to environmental toxicology. Basic terms and definitions of hygiene and epidemiology, short history of hygiene and epidemiology. Detailed explanation of terms such as primary prevention, prevention of diseases by influencing living conditions versus increasing human resistance against unfavourable environmental factors (adaptation, acclimatization, induction of tolerance) or against infection (non-specific and specific immunity, vaccination as an effective tool for infection prevention), a role of government in health protection. Secondary and tertiary prevention. Forms, objectives, practice.
HYGIENE
Man and environment versus importance of lifestyle for human health (individual's, social groups' and populations'). Local problems (industry and transport, chemization of agriculture and xenobiotics in a food basket) and global ones (salination of soil, desertification, acid precipitation, tropical forest devastation, urbanization). Natural, cultivated, artificial, indoor environment and health of man. Minamata disease, yusho disease, itai-itai, black triangle of Europe.
Biological monitoring of environmental pollution and human exposure to xenobiotics. Technical approach to this problem - monitoring networks, legislature. Biological exposure tests, basic terminology and importance of biological limits for toxicants, pollutants in environmental and occupational settings. Practical examples: styrene, trichloroethylene, and alcylating agents. Organophosphorous pesticides, toxic metals. Cytogenetic analyses of peripheral blood lymphocytes. DNA and haemoglobin, albumin adducts detection.
Delayed health effects of xenobiotics. Prenatal exposure. Dose/effect dependence in classical poisons and genotoxic/carcinogenic substances/factors. Mutagenicity, genotoxicity, carcinogenicity, teratogenicity and allergenicity. Delayed effects as a basis for risk assessment of human exposure to environmental xenobiotics and adverse physical factors. Gene mutagenicity (phenylketonuria, galactosemia, chondrodystrophia, haemophilia) chromosomal aberrations-activation oncogens, degenerative diseases/conditions (atherosclerosis, acceleration of ageing). Chromosomal mutations of genome type, aneuploidy, hypo/hyperploidy (syndromes: Down, Turner, Klinefelter). Teratogenic effects (rubella, ionising radiation). Carcinogenicity versus allergenicity of xenobiotics, their presence in environmental and occupational settings.
Maximum acceptable concentrations, threshold limits values, acceptable daily intake. Principles of their establishment - acute, subchronic, chronic laboratory testing, safety coefficients, pilot and follow up epidemiological studies, informed consent, ethical issues. Hygienic standards/limits of separate substances, exposure to mixtures, complex versus combined exposure. MAC/TLV of carcinogenic substances and other xenobiotics (examples: VCM and styrene) - problems in interpretation of animal experimental data versus toxicity to humans. Examples of problems and practical applications in hygienic (environmental) toxicology. Selected examples: manganese, arsenic, beryllium, lead, mercury, cadmium and polyhalogenated hydrocarbons.
Physical factors of environment:
Noise - Physical substance: sound and noise, acoustic pressure, frequency, level, infrasound, ultrasound. Biological effects: specific, local effects (higher levels), systems effects (lower levels). Informative content of the sound, masking, highest sensitivity of human ear. Types of noise: steady, variable, high frequency, with tone components, impulsive. Measuring: steady noise, variable noise. Evaluation limit value. Selected basic values of noise for the Czech Republic. Noise in outdoor space, occupational environment, appartment houses and civil constructions. Prevention and protection: removal of the sources of noise, closing of the source of noise, increasing of distance of noise sources, limitation of time of exposure to noise, use of suitable personal protection aids.
Vibrations (mechanical swinging of elastic environment) - Biological effects: local - vessels, nerves (pneumatic tools, forest saws etc.), general - systems. Vibrations of the frequency lower than 1 Hz - kinetoses. Prevention and protection: shortening the time of exposure to vibrations, protection also against cold and dampness, protective aids, preventive medical examinations, increasing of the risk - vasoactive materials or smoking.
Non-ionising radiation - radio waves (natural, artificial), microwaves (generators, warming ovens, plasma of high temperature), radar waves (radio locators). Physical substance: electrostatic field, magnetic field + electrodynamic field, electromagnetic field - not bound to electric charges, unidirectional currents, alternating currents. Biological effects: thermal, non-thermal. Principles of health protection: time protection, protection by distance, protection by screening (Faraday cages).
Lighting - Day (natural) lighting: factor of day illumination, evenness of lighting, combined day lighting, day lighting map (isophots), limit value of the day illumination factor. Artificial lighting: luminosity, evenness of artificial lighting, artificial lighting map, limit values of luminosity, combined artificial lighting (central and local lighting), temperature of chromatisms. Mixed lighting (simultaneous lighting by day light and supplementing artificial lighting). Disturbing dazzles: dazzle by critical brightness = an absolute dazzle - direct sunshine, electric arcs etc., transitory dazzles - a sudden switch on the light, dazzle by contrast = a relative dazzle - filament of the bulb and surrounding wall.
UV-radiation - Biological effects: UVA, UVB, UVC radiation; Clinical findings: local effects on skin and eye, general (systems) effects, histopathological changes, biochemical and immunologic effects, effect on DNA, carcinogenic effects, germicidal effects, curative effects. Prevention and protection: lower the time exposure, sun filters, glasses.
Ionising radiation - Main sources of ionising radiation exposure in peace conditions. Methods of optimisation X-ray diagnostic and therapy: technical arrangement, organizational arrangement. Principles of protection against radiation: distance, shielding, time. Principles of protection against radioactivity contamination. (Radio) active patient - which received radionuclide. Individual monitoring of persons in external irradiation risk. Individual monitoring of persons in inner contamination risk. Health contra-indications to work in external irradiation risk.
Climatic factors (factors determining human thermal comfort): Climatic elements: air temperature, air humidity, a speed of air streaming, intensity of infrared radiation. Men associated elements: objective (energy issue, thermal resistance of clothes), subjective (adaptation mechanisms, health and psychic conditions, conditions of an organism). Measured quantities: air humidity, air streaming, IR radiation, energy issue - spreadsheet method, thermal resistance of clothes. Evaluation: optimal thermal load, long-term bearing load, short-term bearing load.
Group diagnostics - selected collection, comparison collection or basic collection. Standard deviation method: somatometric examination of school and pre-school age children. Gaussian (normal) distribution, standard deviation, practical exercise on PC.
Indoor/outdoor pollution, sick building syndrome.
Pollution of indoor environment: Building - related difficulties and their causes, especially allergies and asthma and risk factors for them indoors. Non-specific disorders like humidifier fever, hypersensitivity pneumonitis, sick building syndrome, multiple chemical sensitivity syndrome, electrical sensitivity syndrome. Toxic reaction (moulds). Infectious diseases - viral, bacterial. Cancer - especially problems with radon in buildings. Risk factors of the above issues, their prevention and treatment of building and the patient.
Medical approach to outdoors and indoor physical factors: Temperature and humidity. Other physical factors (noise, lighting, and vibration...). Chemical factors - inorganic compounds (NOx, SO2, CO, CO2), ozone. Organic compounds (VOCs, formaldehyde, PAHs). Problems of outdoor pollution in students' countries, associated health risks and their solution.
Tobacco dependence
Epidemiology (prevalence, morbidity and mortality in our country and in the World, trends), different kinds of tobacco use, definitions, passive smoking, environmental tobacco smoke, light cigarettes.
Principle of smoking - psycho behavioural and social dependence, nicotine (drug) dependence, nicotine withdrawal syndrome, Fagerstoem test of nicotine dependence. Measuring of CO in the expired air (Smokerlyzer Bedfont).
Treatment of the tobacco dependence: psycho behavioural treatment and pharmacological treatment. Trends in the Czech Republic and in the World. Economics and health impact of smoking cessation. Smoking cessation clinics. Short intervention (5 minutes) to a smoker should be delivered by each doctor - evidence based guidelines.
Basic legislation and tobacco control.
Nutrition
Significance of specific nutrients (protein, fat, carbohydrates, minerals, vitamins and water).
Food composition, significance of various types of food groups (meat and meat products, milk and milk products, cereals, vegetables, fruits).
Microbiology in nutrition. Food safety requirements, hazards and benefits of microorganisms in nutrition.
Toxicology in nutrition: xenobiotics in food chains. Additives.
Nutrition related diseases (protein energy malnutrition, vitamin and mineral deficiencies) and their importance in public health.
Nutrition guidelines: background, development and implementation.
Nutrition requirements throughout the life cycle. Childhood. Breastfeeding: importance of breast/feeding, dangers of artificial feeding, breast-milk composition, physiology of lactation. Baby friendly hospital initiative, Ten Steps for Successful Breast-feeding. Complementary feeding of infants. Nutrition of toddlers and older children. Recommended dietary allowances and dietary guidelines for adult population. Nutrition in the elderly. 7. Alternative diets and their impact on nutritional status.
Assessment of nutritional status, self-assessment of eating habits. Nutrition counselling.
Water and health
Water and health: physiological importance, water metabolism, and requirements on the quality of drinking water and health hazards. The origin, sources and transport of drinking water. Drinking water treatment, principles of surface water treatment. Drinking water fluoridation, disinfection, ozone, UV radiation, filters. Preparation of drinking water in emergency situations.
Self-cleaning capability of surface water, recreational waters and related health risks. Water-protection zones - importance, problems.
Health hazards: water borne infections (viruses, bacteria, parasites, and worms, nematodes (swimmers itch, Naegleria fowleri, mycoses and other infections). Methaemoglobinaemia as a model of water-related poisoning; differential diagnosis and emergency measures. Waste water - communal, from health facilities and industry draining. Wastewater treatment - principles. Health risks of waste water improper treatment.
Occupational health and industrial hygiene
Basic principles in occupational hygiene - categories of workplaces, workplaces posing health hazard, health saving preventive measures, health contra-indications according to various hazards. Hygienic requirements on working environment Evaluation of work and thermal load - energy output and methods for its assessment. Types of work and their requirements, regimen of work and rest, basic ergonomy.
Basic terms in toxicology. Occupational exposure limits - Maximum Allowable Concentrations (MACs) methodology for its assessment. Biological exposure tests. Acute exposure to harmful substances - poisons: classification, principles of health safety measures in a case of work with poisons.
Late effects of xenobiotics, IARC classification of carcinogens.
Occupational exposure to dust, effects of dust on human health, health protection against dust inhalation. Toxic metals in occupational environment.
Occupational disorders due to exposure to physical agents (noise, vibrations, heat, frost, radiation). Occupational disorders due to chemical agents - gases, organic compounds/solvents. Occupational disorders due to chemical agents - metals. Hygienic issues of work in agriculture; pesticides and fertilizers. Occupational hazards of work in health facilities, health protection. Part of the content is presented in the form of case studies.
EPIDEMIOLOGY
General epidemiology
Definition and history of epidemiology: basic terms used in epidemiology - indicators of morbidity (incidence, prevalence, attack rate), mortality etc.
Epidemiological method of work. Descriptive studies - the basic characteristics of person, place and time. Analytical studies - cohort studies, case and control studies. Advantages and disadvantages, examples. Experimental studies - ethical problems of experiment. Clinical control study, field control study. Method of blind experiment. Natural experiments.
Epidemiology of infectious diseases
Process of spreading infection - characteristic. Elimination and eradication of infection. Etiological agents - pathogenicity, virulence, toxicity, invasiveness, resistance, infection dose. The basic links of the process of spreading infections.
Source of infection - man, animal. Carriers, anthropozoonosis, zoonosis, antroponosis.
The way of transmission. Direct transmission- by contact, by droplet way, transplacental way, perinatal transmission. Indirect transmission - by contaminated objects, by inoculation, by air, by alimentary way, vector - born, by soil.
Susceptible individual. Non - specific resistance, natural non - specific immunity, obtained specific immunity - humoral, cellular.
Methods of fight with infections. The basic preventive measures, antiepidemic measures in the focus of infection - anti-epidemical regime. Epidemiological surveillance.
Cancer epidemiology - basics of cancer epidemiology, trends, risk factors, prevention.
Nosocomial infections
Specific and non-specific nosocomial infections. Exogenous and endogenous nosocomial infections. Occurrence, aetiology, sources, ways of spreading. Prevention and repression. Risk factors. Sterilisation - physical, chemical methods and control. Disinfection - methods. Prophylactic disinfection. Prophylactic disinfestation and deratisation.
Immunization
Vaccination - importance. Herd immunity. The programmes of vaccination.
Types of vaccines, requirement for vaccines, contraindications of vaccination, reactions after vaccinations.
Organisation of vaccination - regular, special, irregular, vaccination before departure abroad and persons coming from abroad, vaccination on accidents, injures and not healing blows. Regular vaccination (tuberculosis, diphtheria, tetanus, whooping cough, poliomyelitis, measles, rubella, mumps etc.)
Special epidemiology
Importance of infectious diseases in history and now. Occurrence of infectious diseases in the world. Specific diseases of this group.
Food/borne diseases - characteristic of group, source, ways of spreading, preventive and repressive measures.
Contact infections of the skin and mucous membranes - characteristic of group, source, ways of spreading, preventive and repressive measures. Specific diseases of this group.
Air-borne infections - characteristic of group, source, ways of spreading, preventive and repressive measures. Specific diseases of this group.
Diseases transmitted by blood - characteristic of group, source, ways of spreading, preventive and repressive measures. Specific diseases of this group.
Vector-borne infections - characteristic of group, source, ways of spreading, preventive and repressive measures. Specific diseases of this group.
Anthropozoonoses - characteristic of group, source, ways of spreading, preventive and repressive measures. Specific diseases of this group.
Statistical methods in hygiene and epidemiology
Introduction in statistical methodology. Descriptive and inductive statistics, statistical induction. Purposive and random sampling methods. Types of random samples. Random variables and their characteristics. Quantitative (continuous and discrete) and qualitative (nominal and ordinal) variables. Measures of location (mean, modus, median) and measures of variability (range, standard deviation, and variance). Basic tools for data presentation (tables graphs).
Random variable and probability distribution. Gaussian (normal) distribution. Basic characteristics of normal distribution. Population Principles of parameter estimation. Estimation of a population means. P% interval of confidence for population mean and for population percentage. Coefficient of confidence, accuracy of an estimate. Planning of epidemiological studies, planning of the sample size.
Principles of statistical hypotheses testing. Null and alternative statistical hypotheses. Test statistic, errors of the first and second types, level of significance. Statistical decision making. Difference between statistical and clinical significance.
Evaluation of epidemiological studies. Measuring of association of risk factors and diseases. Incidence and prevalence. Relative and absolute risks. Tests of hypotheses in four-fold table. Contingency table and Chi-square distribution. Statistical decision making based on four fold and contingency tables, degrees of freedom.
General principles of measuring statistical dependence. Basic requirements on appropriate measures of statistical dependence. Regression and correlation. Pearson correlation coefficient and assumption for his practical use. Linear regression, graphs and interpretation.
Poslední úprava: Kudlová Eva, MUDr., CSc. (11.01.2019)
