Assignment: Safety of Food from Carcinogens
The Office of Food Additive Safety (OFAS) at the Center for Food Safety and Applied Nutrition (CFSAN) of FDA is charged with, among other responsibilities, regulating industry to ensure that food contact substances and food additives are safe.
Using your course textbook, and the Internet, research on major regulations related to food safety. On the basis of your research, answer the following questions:
PRINTED BY: Stephanie Schicchi . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. 379 CHAPTER 14 Injuries with a Focus on Unintentional Injuries and Deaths LEARNING OBJECTIVES By the end of this chapter the reader will be able to: • Define the term intentionality of injury • Describe environmental factors associated with injuries • State time trends in mortality from injuries in the United States • List types of injuries associated with particular age groups, e.g., children, adults, and the elderly • Describe a theoretical framework that is used for injury prevention INTRODUCTION 1 From the worldwide perspective, injuries of all types account for an estimated 5 million deaths annually ; unintentional injuries cause more than 3.5 million deaths, 6 percent of all deaths, and two-thirds of all injury 2 deaths during a typical year. With respect to the United States, unintentional injuries are the fifth leading cause of mortality in the population as a whole and the leading cause of death for the population aged 1 to 3 44 years. These dramatic contributions to mortality (as well as to morbidity) worldwide and domestically often are preventable and can be linked with environmental influences. Accordingly, because of their association with environmental factors, injuries are a noteworthy topic for an environmental health textbook. Chapter 14 delimits the scope of injuries (both intentional and unintentional), describes how environmental factors contribute to such injuries, and suggests methods for prevention of injuries. The field of injury studies covers a vast domain, e.g., car crashes, falls, poisonings, shootings, recreational injuries, and industrial injuries.
The present chapter will focus primarily on unintentional injuries and consider in detail three major areas: motor vehicle injuries and transport-related injuries, life stages and unintentional injuries, and methods of injury prevention. The chapter will also describe methodologics used in injury research, identify some of the most important types of injuries, and discuss the economic impact of injuries. HOW INJURIES ARE CLASSIFIED Specialists in the field of injury research have devoted considerable attention to methods for describing and classifying injuries. Development of a standardized framework for classification of injuries facilitates making comparisons internationally and domestically within the United States. For example, the rates for various types of injuries can be compared more easily from one year to the next as well as across states and regions. Accurate and reliable information helps policy makers develop injury prevention and intervention programs. One of the methods for classifying injuries uses the International Classification of Diseases (ICD) Injury Matrices, which organize injury data into helpful groupings in order to make international and national 4 comparisons. The ICD classifies injuries according to two dimensions: external cause (e.g., car crash) and Essentials of Environmental Health, 2nd Edition Page 1 of 35 PRINTED BY: Stephanie Schicchi . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. nature of the injury or diagnosis (e.g., fracture). Within each of these two dimensions are two axes, which are collapsed into a single code. For example, the first dimension, external cause, is presented as a single code that combines the mechanism of injury (e.g., firearm) and intent of injury (e.g., intentional). The second dimension is the nature of the injury, also a single code for a two-factor variable that aggregates the nature of the injury itself (e.g., open wound) with the region of the body affected (e.g., chest). 379 380 4,5 The term injury refers to “the physical damage [to the person] that results when a human body is suddenly or briefly subjected to intolerable levels of energy. It can be a bodily lesion resulting from acute exposure to energy in amounts that exceed the threshold of physiological tolerance, or it can be an impairment of function resulting from a lack of one or more vital elements (i.e.[,] air, water, warmth), as in drowning, strangulation or freezing. The time between exposure to the energy and the appearance of an injury is 6(p5) Examples of energy that can cause injuries are mechanical force, radiant energy from light or short.” shock waves, extremes of temperature, electrical energy, and chemical energy. Injuries that do not result in death—nonfatal injuries—are defined as “bodily harm resulting from severe exposure to an external force or substance (mechanical, thermal, electrical, chemical, or radiant) or a submersion. This bodily harm can 7 be unintentional or violence-related.” The cause (mechanism) of injury denotes “the way in which the person sustained the injury; how the person was injured; or the process by which the injury occurred. . . .
The underlying cause is what starts the chain of events that leads to an injury. The direct cause is what produces the actual physical harm. The underlying and direct causes can be the same or different. For example, if a person cuts his or her finger with a knife, the cut is both the underlying and direct cause. However, if a child falls and hits his head on a coffee table, the fall is the underlying cause (the action that starts the injury event), and the contact with the 7 table is the direct cause (the action that causes the actual physical harm).” Examples of definitions for causes of nonfatal injuries used by ™ 7 Nonfatal are shown in the text box. (Also see Table 14-1.) Another aspect of injuries is the intent of injury, which refers to “[w]hether an injury was caused by an act 7 carried out on purpose by oneself or by another person(s), with the goal of injuring or killing.” Three terms for classifying the intent of injuries are unintentional, intentional, and undetermined. Intentional injuries include those that result from self-harm (e.g., suicide), legal intervention (e.g., action of the police), interpersonal actions (e.g., assault), and acts of war. An unintentional injury is an “[i]njury or poisoning that is not inflicted by deliberate means (i.e., not on purpose). This category includes those injuries and poisonings described as unintended or “accidental,” regardless of whether the injury was inflicted by oneself or by another person.” 7 Examples of Causes of Nonfatal Injuries Cut/pierce/stab: Injury resulting from an incision, slash, perforation, or puncture by a pointed or sharp instrument, weapon, or object. This category does not include injury from being struck by or against a blunt object (such as the side of a night stand) or bite wounds; these injuries fall in the category “struck by/against.” Essentials of Environmental Health, 2nd Edition Page 2 of 35 PRINTED BY: Stephanie Schicchi . Printing is for personal, private use only.
No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. Inhalation/ingestion/suffocation: Inhalation, aspiration, or ingestion of food or other object that blocks the airway or causes suffocation; intentional or accidental mechanical suffocation due to hanging, strangulation, lack of air in a closed place, plastic bag or falling earth. This category does not include injury resulting from a foreign body that does not block the airway. Natural/environmental: Injury resulting from exposure to adverse natural and environmental conditions (such as severe heat, severe cold, lightning, sunstroke, large storms, and natural disasters) as well as lack of food or water. Poisoning: Ingestion, inhalation, absorption through the skin, or injection of so much of a drug, toxin (biologic or non-biologic), or other chemical that a harmful effect results, such as drug overdoses. This category does not include harmful effects from normal therapeutic drugs (i.e., unexpected adverse effects to a drug administered correctly to treat a condition) or bacterial illnesses. Struck by/against or crushed: Injury resulting from being struck by (hit) or crushed by a human, animal, or inanimate object or force other than a vehicle or machinery; injury caused by striking (hitting) against a human, animal, or inanimate object or force other than a vehicle or machinery. Transportation-related causes: Injury involving modes of transportation, such as cars, motorcycles, bicycles, and trains. This category is divided into four subcategories according to the person injured: motor vehicle occupant, motorcyclist, pedal cyclist, pedestrian, and other transport. This category also involves another factor—whether the injury occurred in traffic (on a public road or highway). Pedal cyclist: Injury to a pedal cycle rider from a collision, loss of control, crash, or some other event involving a moving vehicle or pedestrian. This category includes riders of unicycles, bicycles, tricycles, and mountain bikes. This category does not include injuries unrelated to transport (moving), such as repairing a bicycle. Source: Adapted and reprinted from the Centers for Disease Control and Prevention, Injury Center. Definitions for WISQARS Nonfatal. Available at: http://www.cdc.gov/Ncipc/wisqars/nonfatal/definitions.htm. Accessed May 21, 2010. An unintentional injury is the consequence of an unanticipated event that results in harm or death. The use of the term unintentional injury is preferred to accident; the latter implies a random event that cannot be prevented. Most unintentional injuries are highly preventable; for example, laws that require seat belts and air bags in cars have contributed to a decline in motor vehicle driver and passenger deaths. Other preventive measures include safety messages directed to the public via media campaigns, prohibition of consumption of alcoholic beverages in public parks, school-based safety programs for school children, and licensing of firearms. 380 381 In practice—for example, in some government reports—the terms unintentional injury and accident often are used interchangeably, perhaps because of the public’s familiarity with the latter term and its use in common parlance. An accident is defined as “An unanticipated event—commonly leading to INJURY or other harm—in traffic, the workplace, or a domestic or recreational setting.
The primary event in a sequence that leads ultimately to injury if that event is genuinely not predictable. Epidemiological studies have demonstrated that the risk of accidents is often predictable and that accidents are preventable. This word is Essentials of Environmental Health, 2nd Edition Page 3 of 35 PRINTED BY: Stephanie Schicchi . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. 8 preferably avoided in many types of scientific works.” The World Health Organization states, “There is clear, scientific evidence that injury-related deaths can be avoided and the effect of injury mitigated. . . . [R]esearch, development of data collection systems, the introduction of specific prevention measures such as improvements in the local environment, legislation, public education, product safety, and improvements in the level and quality of emergency care [have led to the reduction of injury deaths among children].” 1 Because the word accident is not in favor as a scientific term, the National Center for Health Statistics has added the term “unintentional injuries” in parentheses next to the category of accidents, the fifth leading 5 cause of death in the United States. The National Highway Traffic Safety Administration (NHTSA) favors the use of the term car crash to accident. Injury epidemiology is a branch of epidemiology that studies the distribution and determinants of injuries in the population. The results of epidemiologic investigations are applied to the prevention and control of injuries. For example, descriptive epidemiologic studies aid in the development of analytic research into the risk factors for and causes of injuries. From this information, policies and procedures to prevent injuries are facilitated. Currently, such research programs may be coupled with ongoing injury surveillance programs and databases that store information about the occurrence of injuries. Chapter 2 covered the use of natural experiments, one of the study designs employed in analytic epidemiology. When new laws to increase safety are adopted (e.g., improvement of automobile safety through the mandatory use of passenger safety belts), they are similar to natural experiments, which can be evaluated by the use of epidemiologic methods. Sources of Injury Data As noted previously, high quality (reliable and valid) data are necessary for developing descriptive and analytic research on the occurrence of and risk factors for unintentional injuries. See Table 14-1 for examples of data sources; as shown in the table, one method for collecting information about injuries is the use of surveillance systems. Public health surveillance refers to the systematic and continuous gathering of information about the occurrence of diseases and other health phenomena. As part of the surveillance process, personnel analyze and interpret the data they have collected and distribute the data and associated findings to planners, health workers, and members of the community. Injury surveillance systems specialize in collecting information about injuries, for example, occupational injuries, motor vehicle injuries, risk behaviors, traumatic brain injuries, and injuries to consumers. In addition to listing information regarding surveillance data, Table 14-1 gives other examples of data sources that may be accessed for information about injuries.
The National Hospital Discharge Survey compiles information about patients who receive hospital care for injuries. The National Vital Statistics System collects and reports data on injuries listed on death certificates. The National Vital Statistics Reports published by the CDC is an example of a report that displays information on the frequency and distribution of intentional and unintentional injuries. Many of the data sources shown in the table can be accessed via the Internet. Essentials of Environmental Health, 2nd Edition Page 4 of 35 PRINTED BY: Stephanie Schicchi . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. THE SIGNIFICANCE OF INJURIES Injuries are a significant phenomenon worldwide because everyone is at risk. As noted, approximately 5 1 million people succumb to fatal injuries worldwide each year. (This total includes both intentional and 9 unintentional injuries.) The death toll from injuries is projected to increase substantially by the year 2020. Beyond the direct harm to people, injuries burden the healthcare system and rehabilitation facilities. The adverse effects caused by injuries include the immediate impact not only upon the affected individual but also upon that person’s family members and social support system. Nonfatal injuries can lead to permanent disability and drastically affect one’s independence—not to mention the pain and suffering that may be 10 experienced by the injured person. Injuries may create stress and severe emotional responses among family members and exact a substantial economic cost. 381 382 TABLE 14-1 Data Sources and Types of Information Available on Injuries Data Source Behavioral Risk Factor Surveillance System Sponsor The CDC Population Coverage Information Available All of United States (persons Risk behaviors for leading aged 18 years old and older) causes of injury and death; injury-related data, e.g., occurrence of falls, use of seat belts. Central nervous system The CDC Participating US states Extent of injury among surveillance: traumatic brain persons who experience injury (TBI) TBIs. Risk factors for TBI. National Electronic Injury US Consumer Product Safety US hospitals Originally for injuries Surveillance System—All Commission associated with consumer Injury Program products. Now includes all nonfatal injuries treated in hospital emergency departments. National Hospital Discharge The CDC—National Center US national sample of about Injuries among persons who Survey for Health Statistics 500 hospitals survive and are discharged from inpatient hospital care. National Vital Statistics The CDC—National Center All of United States Deaths causes by injuries System for Health Statistics and violence. Web-based Injury Statistics The CDC All of United States Injury morbidity and Query and Reporting System mortality data. Fatal and (WISQARS) nonfatal unintentional and violent injuries. Permits online user queries via interactive database. Source: Data from National Center for Injury Prevention and Control. CDC Injury Fact Book. Atlanta, GA: Centers for Disease Control and Prevention; 2006:16. Noteworthy is the fact that injuries manifest characteristic social and demographic distributions, 6 disproportionately affecting the poor in all countries of the world. A total of 90% of unintentional injury 2 deaths transpire in low- and middle-income countries. Some environmental conditions found in many less developed countries increase the likelihood of unintentional injuries; these aspects of the environment Essentials of Environmental Health, 2nd Edition Page 5 of 35 PRINTED BY: Stephanie Schicchi . Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher’s prior permission. Violators will be prosecuted. include poorly maintained sidewalks, lack of paved streets, unavailability of pedestrian zones in cities, public transportation facilities in disrepair, and unsafe working conditions in factories. At the international level, persons between the ages of 5 and 44 years are at special risk of injuries of all types; among this age group injury-related causes account for 6 of the 10 leading causes of death. About half of injury-related mortality occurs in the group aged 15 to 44 years; mortality from injuries among men 9 is double that among women. Injuries account for approximately one-third of deaths among children aged 1 to 14 years in Europe, although death rates differ greatly between Eastern and Western European 11 countries. For example, the main contributors to injury deaths among children in the former Soviet Union countries of Eastern Europe are drowning, poisoning, fires, and falls. Traffic-related injuries are the leading cause of injury-related mortality among children and young people in the northwestern part of Europe. In the United States, all forms of injuries accounted for 179,065 deaths during 2006. (Refer to Figure 14-1.) These were distributed according to the five general categories shown on the left of Figure 14-1. These categories, defined according to International Classification of Diseases (ICD) codes, are unintentional injuries, suicide, homicide, undetermined, and legal intervention/war (shown as legal intervention in the figure). The three leading causes of death from injuries were unintentional injuries, suicide, and homicide. Fatalities from unintentional injuries are discussed later in the chapter. Note that these aggregate categories can be subdivided into finer subcategories and rearranged into other classifications. For example, the general category of suicide …
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