Sentinel health events of environmental contamination: a consensus statement.

The Agency for Toxic Substances and Disease Registry (ATSDR) has specific interest in surveillance methods as part of its studies of health effects potentially associated with environmental contamination sites (1,2). An earlier ATSDR-sponsored conference , held 30 October-1 November 1989 in Asheville, North Carolina, laid much of the groundwork for considering a specific listing of health events as candidates for this sentinel application (3). This report is the product of a sequel conference charged to review the available scientific literature, assimilate relevant experiences, and produce a framework for a listing of sentinel health events (SHEs) for use in monitoring health around sites of environmental contamination. This consensus panel was convened 18-19 May 1992 at the University of North Carolina, Chapel Hill, to identify SHEs that could serve as indicators of environmental contamination. Early in the conference there were several presentations building upon Rutstein's original supposition regarding SHEs (4). Recent other works relating to the use of sentinel events in public health surveillance were also discussed (5-9). Two days of deliberations followed. Presented here are the consensus statements and recommendations that resulted from this endeavor. Type L The following acute conditions are regarded as SHEs in the form of the definition by Rutstein (1): 1) poisonings, especially due to pesticides, metals, or other agents that might be found in waste streams, in disposal sites, or other accessible locations. Children are especially vulnerable to this hazard. Lead and carbon monoxide poisoning are SHEs. Cholinesterase inhibition would also be classified under poisoning; 2) selected cancers that are specific for known physical or chemical agents. In general, cancers are poor SHEs because of their long latencies. Some cancers whose biology is sufficiently well studied may be considered SHEs, e.g., mesothelioma, clear cell cancer of the vagina, and angiosarcoma of the liver; 3) precocious puberty or thelarche. Many pesticides, industrial chemicals, and food additives have estrogenic activity. Precocious puberty is so rare that an inquiry into possible sources of estrogen exposure is warranted ; 4) methemoglobinemia is a classic poisoning. It was included from the previous panel's work (4); 5) toxic neuropathy. Elicitation of an unusual exposure to a toxic agent is required to make a diagnosis of toxic neuropathy; i.e., with Minimata disease, the case definition includes exposure to methylmercury. Type II. Unusual health patterns (e.g., statistically significant excess cases or space-time patterns) in incidence of the following conditions, identified via general surveillance , …