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CEDEP Regional Epi Meeting Montgomery Bell State Park April 30, 2014

ENVIRONMENTAL. CEDEP Regional Epi Meeting Montgomery Bell State Park April 30, 2014 Joe George, Sutapa Mukhopadhyay, David Borowski, Craig Shepherd – CEDEP - EEP. Eve of Christmas Eve Dinner. Extended family gathering 4 adults 2 children. Chili, hot dogs, French fries, coleslaw.

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CEDEP Regional Epi Meeting Montgomery Bell State Park April 30, 2014

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  1. ENVIRONMENTAL • CEDEP Regional Epi Meeting • Montgomery Bell State Park • April 30, 2014 • Joe George, Sutapa Mukhopadhyay, David Borowski, Craig Shepherd – CEDEP - EEP

  2. Eve of Christmas Eve Dinner • Extended family gathering • 4 adults • 2 children • Chili, hot dogs, French fries, coleslaw • An adult becomes violently ill • Tingling in face • Nausea • Vomiting • Diarrhea

  3. …3 Hours Later… • Seeks medical treatment at Veterans Affairs hospital • Patient admitted December 2013 • Ventilator • Hospitalized 3 weeks • Discharged in January 2014 • Patient and family did not return to their home

  4. Patient’s Medical/Social History • Adult male – mid 40s • Military Veteran • Restricted diet • Does not work • Does not leave the house a great deal • Something else…

  5. A Household Mystery ENVIRONMENTAL • Veterans Affairs medical doctor requests assistance from TDH • Dr. May brought the case to EEP • Metals testing revealed barium in blood • Patient believed something in his home was causing his illness • Home was new construction when purchased in October 2010 • Symptoms began in January 2011 • Illness continued while in home -hospitalized ~16 other times

  6. Blood Barium ENVIRONMENTAL Patient’s measured blood barium level ~14,000 ng/mL = 14,000 µg/L = 1,400 µg/dL Published “normal ranges” in literature: 30 – 200 µg/L 30 – 290 µg/L 80 – 400 µg/L Level is 35 to 70 times higherthan high end of “normal range”

  7. What is Barium (Ba2+) ? • A silvery-white metal • Exists in nature in ores containing amixture of elements • Combines with other chemicals to formbarium compounds • Commercial Uses: • drilling mud • paint • bricks • ceramics • pesticides • medical tests (opaque medium) ENVIRONMENTAL

  8. Acute Barium Toxicity • Symptoms: • gastrointestinal disturbances (vomiting, abdominal cramps, diarrhea) • muscle weakness (face numbness) • paralysis • changes in heart rhythm • hypokalemic periodic paralysis • Not likely to be carcinogenic to humans • Do not know if children are moreor less sensitive than adults

  9. Suspected Sources Patient must have recently ingested something to have elevated blood barium • rat poison • brazil nuts • fireworks • supplement • seaweed • fish • major dietary sources such asmilk, potatoes, and flour • soil or water ENVIRONMENTAL

  10. EEP’s Investigation ENVIRONMENTAL • Conducted phone conferences withpatient’s VA doctor • Conducted phone conferences withTN Poison Center • 85-question conference call survey with patient

  11. EEP’s Investigation ENVIRONMENTAL • Survey included questions about: • family • house • occupational history • medical history • military deployment history • food habits • social history/behaviors • water source • neighborhood • hobbies • travel history

  12. EEP’s Investigation ENVIRONMENTAL • Recommended patient be retested –VA will not test unless symptoms return • Recommended other family members have blood tested – done • Conferred with TDEC, ATSDR, TN Poison Center, and EPA • Requested EPA Emergency Response assistance to investigate itemsin home • Scheduled home visit

  13. Home – Looking for a Clue • EEP, EPA, and TDEC met patient’s wife at home – provided access Friday, February 28, 2014 • EPA used portable X-ray Fluorescence unit • XRF scanner measuresmanymetals • State Lab analyzedsoil, water, and dust • Patient stopped by

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  16. Findings ENVIRONMENTAL • Nothing found in the home with XRF suggesting a source for patient’s elevated blood barium • Drinking water tested well belowEPA’s MCL or RSL • Soil tested well below EPA’s RSL • Vacuum cleaner dust tested well below EPA’s RSL for soil

  17. Follow Up ENVIRONMENTAL • Informed patient’s doctor at VA • Informed patient and family byphone and letter with analyticalresults of water, soil, and vacuumdust • Informed TN Poison Center • Will provide patient with EPA SiteInvestigation Report when available

  18. Other Stuff ENVIRONMENTAL • “suspect” • Patient still believes the house is • We won’t know if patient’s illnessand symptoms are related to bariumunless patient gets sick and is testedagain • Reported case of intentional bariumpoisoning in TN • Surveillance for heavy metals

  19. Uncertainties ENVIRONMENTAL • Blood tested only once for barium • Patient’s other medical conditions • Chance for units of results to bemisreported • Chance for blood samplecontamination • No blood barium confirmation test • No other family members ill

  20. ENVIRONMENTAL

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