Environmental Review: Magico-Religious Mercury Use in Caribbean and Latino Communities: Pollution, Persistence, and Politics

Surgical Management of Iatrogenic Mercury Poisoning From Subcutaneous Injection Into the Arm

BACKGROUND

Mercury, an element with threats of severe toxic insult to humans and no biological function, has a surprisingly extensive record of human exposure. Regardless of hesitancies toward its harmfulness, it has been historically identified with an almost supernatural power to provide protection from evil and sickness, give good fortune, lend aid in athletic undertakings, or even allow one to achieve immortality. Mercury poisoning is an iatrogenic disease even today as people attempt to achieve these effects through volitional injections into their body by practitioners. Although an uncommon practice in the United States, awareness of patient presentation after volitional injections of elemental mercury is necessary for appropriate treatment of these patients. We aim to increase awareness of the cultural practice of subcutaneous injections of mercury, as it is uncommonly seen in the United States, to contribute a broader understanding to the patient's medical presentation and describe an approach and the impact of medical and surgical intervention.

METHODS

In this report, we describe a rare case of elemental mercury poisoning secondary to volitional subcutaneous injection to the arm. Initial management of care through chelation therapy and monitoring of renal and serum mercury levels in addition to symptoms of systemic spread was overseen by an internal medicine physician and poison control. Surgical intervention via full-thickness excision of the visible mercury to the right arm followed by local flap and skin grafting reconstruction was performed.

CONCLUSIONS

Mercury poisoning from intentional subcutaneous administration is an uncommon patient presentation in the United States; however, knowledge of management of this rare condition is important for effective management of iatrogenic mercury toxicity.

Combining ecological, eco-cultural, and environmental justice parameters to create Eco-EJ indicators to monitor cultural and environmental justices for diverse communities around contaminated sites

Assessing environmental quality often requires selection of indicators that can be employed over large spatial scales and over long-time periods to assess the health and well-being of species, natural communities, and ecosystems, and to detect changes warranting intervention. Typically, the ecologic environment and the human environment are evaluated separately and selection of indicators and monitoring approaches are not integrated even though ecological indicators may also provide information on risk to human consumers from contaminants (e.g., eco-cultural indicators) or because of disease levels. This paper is a call for ecologists and managers to consider diverse cultural and environmental injustice disparities and health issues when selecting indicators for environmental assessment and monitoring. There is an opportunity for managers and community members to work together to preserve ecological and cultural resources and heritages. We propose a paradigm that selects indicators and monitoring approaches that lend themselves to the integration of human-diversity and uniqueness in the same manner that the selection of ecological indicators and monitoring approaches consider biological species diversity and uniqueness. The proposed paradigm builds on ecological risk assessment techniques, developing analogous endpoints for neighboring communities. For example, identification and protection of human communities, particularly culturally diverse and environmental justice communities, identification of contaminant corridors (e.g., through water or green corridors) into communities, and eco-monitoring of vulnerable communities are not routine at contaminated sites. Green corridors refers to a width of wild habitat (forest, grasslands) that connects other similar habitat paths (usually a corridor runs through an urban or suburban habitat). We coin the term Eco-EJ indicators for these endpoints, including examination of (1) unique cultural relationships to resources; (2) connectedness of on-site and off-site resources and habitats; (3) health of threatened, rare, and unique cultures and communities; and (4) linkages between ecological, eco-cultural, and public health for monitoring and assessment. We also propose that assessment and monitoring include these Eco-EJ indicators, especially for communities near facilities that have extensive chemical or radiological contamination.Developing these indicators to assess risk to culturally diverse and environmental justice communities would be an equivalent goal to reducing risk for significant ecological resources (e.g., endangered species, species of special concern). These Eco-EJ indicators are complementary to the usual human health-risk assessments, would include surveys of neighboring vulnerable communities, and require time and re-organization of current data and additional data collection at site boundaries and in adjacent communities, as well as rethinking the human component of indicators. This approach lends itself to addressing some diverse cultural and environmental justice issues with current indicator selection and biomonitoring, and helps identify specific hotspots of unique ecosystem risk and environmental justice community risk. We briefly discuss ecological and eco-cultural monitoring already on-going at three Department of Energy sites to illustrate how the addition of these indicators might work and add value to environmental management and to their relationships with surrounding communities. We recommend that managers of contaminated sites convene people from culturally diverse communities, environmental justice communities, local and federal government, Tribes, resource trustees, managers, and other stakeholders to develop appropriate site-specific indicators to address environmental inequities around contaminated facilities.

Sources of Mercury Exposure to Children in Low- and Middle-Income Countries

BACKGROUND

Many children in low- and middle-income countries face enhanced risks of exposure to contaminants via the environment, parental occupation, and other routes. While mercury (Hg) is a global pollutant whose transport properties allow it to have an impact even in pristine areas, the presence of significant Hg sources in the developing world can cause localized effects that are more severe than those observed in other areas.

OBJECTIVES

This paper provides a narrative review of sources of Hg exposure to people in the developing world with a particular focus on children, and presents an overview of key aspects to this important issue.

METHODS

We searched Web of Knowledge and Google Scholar using keywords including combinations of "mercury" and one or more of the following: "children," "exposure," "breast milk," "artisanal mining," "prenatal," "religion," "medicine," "dental amalgam," "chlor-alkali," "VCM," "vaccine," "e-waste," "industry," "beauty," "cosmetics," "strategies," "child labor," "costs," and "developing countries" to find peer-reviewed articles pertaining to Hg exposure in the developing world.

RESULTS

Sources of Hg exposure include mining, consumption, industrial operations, religious practices, traditional medicines, beauty products, vaccines, dental amalgams, and waste scavenging and recycling.

CONCLUSION

Children in the developing world are often subject to higher levels of Hg exposure than those living in developed countries due to the higher prevalence of Hg-intensive industrial processes and consumer products, lack of environmental regulation, and limits in mobility and food choices, among other factors. This issue can be addressed through additional research to fill in data gaps on exposure sources, establish sound and enforceable policies, and increase education and participation in affected communities. Challenges to addressing this problem include limited resources for needed equipment, training, and manpower to implement solutions.

Assessment of prenatal mercury exposure in a predominately Caribbean immigrant community in Brooklyn, NY

Prenatal mercury exposure and its fetotoxic effects may be of particular concern in urban immigrant communities as a result of possible contributing cultural factors. The most common source of exposure in these communities is ingestion of fish and shellfish contaminated with methylmercury. Other sources of exposure may occur in ritualistic practices associated with Hispanic and Caribbean-based religions. This study 1) assessed total mercury levels in both random urine specimens from pregnant women, and in cord blood; and 2) examined environmental sources of exposure from a convenience sample in a predominantly Caribbean immigrant population in Brooklyn, New York. A questionnaire designed in collaboration with health professionals from the Caribbean community assessed the frequency of fish consumption, ritualistic practices, occupational exposures, and use of dental amalgams and mercury-containing skin and household products. The geometric mean for total mercury in cord blood was 2.14 μg L(-1) (95%CI: 1.76-2.60) (n = 78), and 0.45 μg L(-1) (95%CI: 0.37-0.55) (n = 183) in maternal urine corrected for creatinine (μg g(-1)). Sixteen percent of cord blood mercury levels exceeded the estimated equivalent of U.S. Environmental Protection Agency's Reference Dose (5.8 μg L(-1) blood). Predictors of cord blood mercury included maternal fish consumption and foreign birth of the mother. Predictors of urine mercury included foreign birth of the mother, number of dental amalgams, and special product use. There were no reports of mercury use in ritualistic practices or in cosmetics; however some women reported use of religious medals and charms. This study characterized risk factors for mercury exposure in a sample of urban, predominantly Caribbean-born blacks. Findings may help target interventions in this population, which might include appropriate fish selection and consumption frequency during pregnancy, and safe handling of mercury-containing products in the home.

Disproportionate exposures in environmental justice and other populations: the importance of outliers

We examined traditional environmental justice populations and other groups whose exposure to contaminants is often disproportionately high. Risk assessment methods may not identify these populations, particularly if they are spatially dispersed. We suggest using a National Health and Nutrition Examination Survey approach to oversample minority communities and develop methods for assessing exposure at different distances from pollution sources; publishing arithmetic and geometric means and full distributions for minority populations; and paying particular attention to high-end exposures. Means may sufficiently characterize populations as a whole but are inadequate in identifying vulnerable groups and subgroups. The number of individuals above the 95th percentile of any distribution may be small and unrepresentative, but these outliers are the ones who need to be protected.

A review of events that expose children to elemental mercury in the United States

Concern for children exposed to elemental mercury prompted the Agency for Toxic Substances and Disease Registry and the Centers for Disease Control and Prevention to review the sources of elemental mercury exposures in children, describe the location and proportion of children affected, and make recommendations on how to prevent these exposures. In this review, we excluded mercury exposures from coal-burning facilities, dental amalgams, fish consumption, medical waste incinerators, or thimerosal-containing vaccines. We reviewed federal, state, and regional programs with data on mercury releases along with published reports of children exposed to elemental mercury in the United States. We selected all mercury-related events that were documented to expose (or potentially expose) children. Primary exposure locations were at home, at school, and at others such as industrial property not adequately remediated or medical facilities. Exposure to small spills from broken thermometers was the most common scenario; however, reports of such exposures are declining. The information reviewed suggests that most releases do not lead to demonstrable harm if the exposure period is short and the mercury is properly cleaned up. Primary prevention should include health education and policy initiatives.

A review of events that expose children to elemental mercury in the United States

OBJECTIVE

Concern for children exposed to elemental mercury prompted the Agency for Toxic Substances and Disease Registry and the Centers for Disease Control and Prevention to review the sources of elemental mercury exposures in children, describe the location and proportion of children affected, and make recommendations on how to prevent these exposures. In this review, we excluded mercury exposures from coal-burning facilities, dental amalgams, fish consumption, medical waste incinerators, or thimerosal-containing vaccines.

DATA SOURCES

We reviewed federal, state, and regional programs with information on mercury releases along with published reports of children exposed to elemental mercury in the United States. We selected all mercury-related events that were documented to expose (or potentially expose) children. We then explored event characteristics (i.e., the exposure source, location).

DATA SYNTHESIS

Primary exposure locations were at home, at school, and at other locations such as industrial property not adequately remediated or medical facilities. Exposure to small spills from broken thermometers was the most common scenario; however, reports of such exposures are declining.

DISCUSSION AND CONCLUSIONS

Childhood exposures to elemental mercury often result from inappropriate handling or cleanup of spilled mercury. The information reviewed suggests that most releases do not lead to demonstrable harm if the exposure period is short and the mercury is properly cleaned up.

RECOMMENDATIONS

Primary prevention should include health education and policy initiatives. For larger spills, better coordination among existing surveillance systems would assist in understanding the risk factors and in developing effective prevention efforts.

Mercury exposure in young children living in New York City

Residential exposure to vapor from current or previous cultural use of mercury could harm children living in rental (apartment) homes. That concern prompted the following agencies to conduct a study to assess pediatric mercury exposure in New York City communities by measuring urine mercury levels: New York City Department of Health and Mental Hygiene's (NYCDOHMH) Bureau of Environmental Surveillance and Policy, New York State Department of Health/Center for Environmental Health (NYSDOHCEH), Wadsworth Center's Biomonitoring Program/Trace Elements Laboratory (WC-TEL), and Centers for Disease Control and Prevention (CDC). A previous study indicated that people could obtain mercury for ritualistic use from botanicas located in Brooklyn, Manhattan, and the Bronx. Working closely with local community partners, we concentrated our recruiting efforts through health clinics located in potentially affected neighborhoods. We developed posters to advertise the study, conducted active outreach through local partners, and, as compensation for participation in the study, we offered a food gift certificate redeemable at a local grocer. We collected 460 urine specimens and analyzed them for total mercury. Overall, geometric mean urine total mercury was 0.31 microg mercury/l urine. One sample was 24 microg mercury/l urine, which exceeded the (20 microg mercury/l urine) NYSDOH Heavy Metal Registry reporting threshold for urine mercury exposure. Geometric mean urine mercury levels were uniformly low and did not differ by neighborhood or with any clinical significance by children's ethnicity. Few parents reported the presence of mercury at home, in a charm, or other item (e.g., skin-lightening creams and soaps), and we found no association between these potential sources of exposure and a child's urinary mercury levels. All pediatric mercury levels measured in this study were well below a level considered to be of medical concern. This study found neither self-reported nor measured evidence of significant mercury use or exposure among participating children. Because some participants were aware of the possibility that they could acquire and use mercury for cultural or ritualistic purposes, community education about the health hazards of mercury should continue.