There have been two shifts in our environmental concerns since the early environmental movement in the 1960's and 1970's. The first has been a shift from a strictly ecological focus, where concerns centered on man's negative effects on the natural world, to concern specifically about the risks posed to human health. Even more focused has been our interest in children's health. The second shift has been to be more attentive to the environmental risks associated with the "built" environment: our homes, office buildings, and schools. This shift has helped to raise awareness about indoor air quality; the existence of and manner by which we control pests (including insects, molds, fungus/mildew, and rodents); and the health risks associated with the products that we use to construct buildings and those products that we bring into our homes, schools, and offices. Increasingly, concerns are being raised about school buildings, the built environment that one sixth of the U.S. population can be found in, Monday through Friday, during the school year. Our concerns are further heightened because the majority of people found in school buildings are children, who may have distinct vulnerabilities to environmental health risks.

There are some quick fixes that can be accomplished for school-based environmental health risks but some environmental health problems will have existed for years; identifying and reducing them may take time. Some risks are quite complex and will require changes in purchasing practices; rehab and renovation specifications; and upgrades of ventilation systems. The best way to address any of the problems will be from an informed position and with the support of others in the education setting. Take time to read the section on health and safety committees; health and safety committees can create a win-win platform for creating environmentally healthy schools that will be safe workplaces and healthy learning places.

Toxicology, a critical science in environmental health, is the study of the negative effect of a physical stressor (chemical, biological, or radioactive) on a biological system (a cell, tissue, organ, organ system, or organism). The key variables in determining the relationship between an exposure to a stressor and a health effect are: 1) the "dose" of the exposure; 2) the "duration" of the exposure; 3) the "toxicity" or strength of the toxin; and 4) a variety of "host factors" (such as age, sex, health status, other exposures). Environmental toxins can enter the human body by ingestion, inhalation, and dermal exposure. People may ingest toxic chemicals in their drinking water, as well as foods and beverages. Air pollutants can affect many body systems. Some toxic exposures, such as solvents and some pesticides, can be absorbed through the skin.

In the same way that the desired effects of pharmacological agents are dose-dependent and depend on host factors, the effects elicited by toxic chemicals in our environment are dose-dependent and dependent on host factors. This concept is extremely important when discussing children's special vulnerabilities to environmental exposures because a number of variables influence the dose of toxic chemicals to which children are exposed.

Most people are aware that outdoor air pollution can pose health risks, but many do not know that indoor air pollution can also have significant health effects. Environmental Protection Agency (EPA) studies of human exposure to air pollutants indicate that indoor levels of pollutants may be 2-5 times, and occasionally more than 100 times, higher than outdoor levels. These levels of indoor air pollutants may be of particular concern because most people spend about 90 percent of their time indoors. Perhaps the most sensitive of school building inhabitants are asthmatic children. Based on a 1997 National Health Interview Survey (CDC, 2001), it was estimated that 25.7 million people had been diagnosed with asthma by a health professional in their lifetime. That estimate increased to 26.3 million in 1998. The highest prevalence was seen in children 5-17 years of age, with 130.1 per 1,000 in 1997 and 135.0 per 1,000 in 1998 (CDC, 2001). Asthma accounts for an estimated 10.1 million lost school days annually (CDC, 2001).

Asthma Triggers Include
Allergic Reactions:	pollens, feathers, molds, animals, some Foods, house dust, latex
Infections:	Influenza, Pneumonia
Second Hand Smoke Cockroaches Emotional Stress & Excitement Vigorous Exercise Cold Air
Occupational Dust & Vapors:	plastics, grains, metals, wood, sulfur dioxide, auto exhaust, grains, ozone
Sleep (Nocturnal Asthma)
Household Products:	paint, cleaners, sprays, drugs, aspirin
Heart Medications
www.lungusa.org/asthma/astastrig.html

In recent years, comparative risk studies performed by EPA and its advisory board have consistently ranked indoor air pollution among the top five environmental risks to public health. Children may be especially susceptible to air pollution. The same concentration of pollutants can result in higher body burdens in children than adults because children breathe a greater volume of air relative to their body weight.

Over the past several decades, our exposure to indoor air pollutants has increased due to a variety of factors, including the construction and renovation of more tightly sealed buildings, reduced ventilation rates to save energy, the use of synthetic building materials and furnishings, and the use of personal care products, pesticides, and housekeeping supplies. In addition, our activities and decisions, such as deferring maintenance to "save" money, can lead to problems from sources and ventilation. Indoor air pollutants can originate within the building or be drawn in from outdoors. If pollutant sources are not controlled, indoor air quality (IAQ) problems can arise, even if the heating ventilation and air condition (HVAC) system is properly designed, operated, and maintained. Air contaminants consist of particles, dust, fibers, bioaerosols, and gases or vapors.

Indoor air pollutant concentration levels can vary by time and location within the school building, or even a single classroom. Pollutants can be emitted from point sources, such as science storerooms, or from area sources, such as newly painted surfaces. Also, pollutants can vary with time, such as only when floor stripping is done, or continuously, such as mold growing in the HVAC system.

Heating, ventilation, and air condition system design and operation can impact the temperature, humidity, and contaminant level in the building. The heating, ventilation, and cooling system includes all heating, cooling, and ventilating equipment serving a school: boilers or furnaces, chillers, cooling towers, air handling units, exhaust fans, ductwork, and filters. A properly designed and functioning HVAC system:

• Controls temperature and relative humidity to provide thermal comfort
• Distributes adequate amounts of outdoor air to meet ventilation needs of school occupants
• Isolates and removes odors and other contaminants through pressure control, filtration, and exhaust fans.

Not all HVAC systems are designed to accomplish all of these functions. Some buildings rely only on natural ventilation. Others lack mechanical cooling equipment, and many function with little or no humidity control.

Nurses are often the only health care providers in the school setting. School nurses are aware of the health status of the students and those with particular vulnerabilities. This knowledge and awareness places school nurses in a special position to make a link between health effects experienced by the school population and the environmental conditions within the school. School nurses have a tremendous opportunity to educate students, parents, and staff and provide resources regarding IAQ issues. By tracking and documenting symptoms, and association with particular rooms or areas in the school building, nurses can provide a crucial role in connecting health complaints to the school environment.

Indoor Air Quality problems are most likely to affect those with preexisting health conditions and those who are exposed to tobacco smoke. Student health records should include information about known allergies and other medically documented conditions, such as asthma, as well as any reported sensitivity to chemicals. Privacy considerations may limit the student health information that can be disclosed, but to the extent possible, information about students' potential sensitivity to IAQ problems should be provided to teachers. This is especially true for classes involving potential irritants (e.g., gaseous or particle emissions from art, science, or industrial/vocational education sources).

"Pesticides are substances intended to destroy, control or repel pests, such as insects, weeds, fungi, rodents, and bacteria. Depending upon the dose, pesticides may cause a range of harm such as cancer, acute or chronic injury to the lungs, nervous, reproductive, and endocrine and immune system damage and may accumulate in the environment. Children are at greater risk of pesticide exposure than adults because pound for pound of body weight, children not only eat more and breathe more, but they also have a more rapid metabolism than adults and they play on the floor and lawn where pesticides are commonly applied".

There is a growing body of scientific data about the harmful effects that pesticides have on children's health, both acute and chronic. Acute affects of exposure include eye and throat irritation, skin rashes, nausea, vomiting, diarrhea, headaches, flu-like symptoms, upper respiratory distress, and in extreme cases, death. Chronic effects (those that appear long after exposure) include an increased risk of some types of cancer, reproductive impairment, and neurological damage (US EPA, 1999). Several studies have examined the relationship between childhood cancers (brain cancer, Ewing's sarcoma, Wilm's tumor, acute lymphoblastic leukemia, non-Hodgkin's lymphoma) and pesticide exposures (McBride, 1998; Daniels, 1997; Buckley, 2000; Meinert, 2000; Infante-Rivard, 1999). The potential risks illustrated by these studies suggest a need for a precautionary approach when dealing with pesticide exposures and children.

"Integrated pest management [IPM] is an increasingly useful approach to minimizing pesticide use while providing long-term pest control. It integrates both chemical and non-chemical methods to provide the least toxic alternative for pest control" (American Academy of Pediatrics, 1999). Traditional pest control has relied heavily on pesticides as the first plan of attack. IPM differs in that it does not automatically rely on pesticide application. Schools should adopt an official IPM statement to serve as a guide for the process of development, implementation, and evaluation of a program. If no IPM program exists, a committee should be organized to develop a program.

For more information on IPM in schools, the Environmental Protection Agency has the following resources available: Pest Control in School Environments: Adopting Integrated Pest Management is a brochure that identifies ways for schools to reduce dependence on pesticides in school buildings and landscapes and discusses alternative methods for managing pests commonly found in schools. To order a free copy, call (800) 490-9198. EPA's web site on IPM in schools that provides information on EPA's efforts to reduce children's exposure to pesticide use in schools. A national directory of IPM in schools web sites created to assist individuals with finding specific information about each state IPM program, as well as appropriate IPM state contacts is available at: http://schoolipm.ifas.ufl.edu/ipm_org.htm. Other EPA publications include: Recognition and Management of Pesticide Poisonings Pesticides and Food: What You and Your Family Need to Know Ten Tips to Prevent Pesticide and Lead Poisonings Citizen's Guide to Pest Control and Pesticide Safety To order free copies of the publications listed above, call (800) 490-9198.

The EPA has banned, or phased out the use of two older pesticides that do not provide an adequate margin of protection for children. Chlorpyrifos - On June 8, 2000, the EPA announced an agreement with chemical manufacturers to phase out the home and garden uses of this insecticide by the end of the year, but the agreement will allow existing stocks to be depleted. It will continue to be used on all foods (except tomatoes), golf courses, green houses, mosquitos, and for fire ant control. New home treatment for termites with chlorpyrifos will continue until December of 2005. More information Diazinon - The EPA has recently banned over-the-counter sales of the insecticide Diazinon. However, individuals may not be aware of this and may continue to use their inventories in homes and schools. The EPA has not yet eliminated all uses of Diazinon. More information These chemicals should not be placed in the trash. Any inventories should be taken to a hazardous waste facility for disposal.

General First Aid Guidelines For Pesticide Exposure: Swallowed poison. Induce vomiting ONLY if emergency personnel on the phone tell you to do so. It will depend on what the child has swallowed; some petroleum products or caustic poisons will cause more damage if the child is made to vomit. Always keep Syrup of Ipecac on hand (1 ounce for each child in the household) to use to induce vomiting if recommended by emergency personnel. Be sure the date is current. Poison in eye. Eye membranes absorb pesticides faster than any other external part of the body; eye damage can occur in a few minutes with some types of pesticides. If poison splashes into an eye, hold the eyelid open and wash quickly and gently with clean running water from the tap or a gentle stream from a hose for at least 15 minutes. If possible, have someone else contact a Poison Control Center for you while the victim is being treated. Do not use eye drops or chemicals or drugs in the wash water. Poison on skin. If pesticide splashes on the skin, drench area with water and remove contaminated clothing. Wash skin and hair thoroughly with soap and water. Later, discard contaminated clothing or thoroughly wash it separately from other laundry. Inhaled poison. Carry or drag victim to fresh air immediately. If you think you need protection such as a respirator and one is not available to you, call the fire department and wait for emergency equipment before entering the area. Loosen victim's tight clothing. If the victim's skin is cyanotic or the victim has stopped breathing, give artificial respiration and call rescue service for help. Open doors and windows so no one else will be poisoned by fumes. Additional pesticide product information can be obtained from the National Pesticide Telecommunications Network (NPTN) at (800) 858-7378. NPTN is a toll-free information service operated seven days a week from 6:30 a.m. - 4:30 p.m, PST (9:30 a.m. - 7:30 p.m. EST) , excluding holidays. E-mail | Web site. Also at NPTN is the National Antimicrobial Information Network (NAIN) which provides informationabout antimicrobial products - sanitizers, disinfectants, and sterilands. Telephone 1-800-447-6349, 6:30 a.m. - 4:30 p.m, PST excluding holidays. FAX: 1-541-737-0761. E-mail | Web site | Mailing address: NAIN, Oregon State University, 333 Weniger Hall, Corvallis, OR 97331-6502.

Asbestos is a mineral fiber. It can be positively identified only with a special type of microscope. There are several types of asbestos fibers. In the past, asbestos was added to a variety of products to strengthen them and to provide heat insulation and fire resistance.

Formaldehyde is one in a large family of chemical compounds called volatile organic compounds or "VOCs." The term volatile means that the compounds vaporize at normal room temperatures. Some VOCs can cause watery eyes, burning sensations in the eyes, nose and throat, nausea, coughing, chest tightness, wheezing, skin rashes, and allergic reactions. Humidity and temperature will affect the off-gassing (release of gaseous chemicals from a solid material) of formaldehyde from products such as pressboard. Pressboard is commonly found in temporary school buildings. Although professional advice should be solicited to resolve concerns, the school can immediately respond to this concern by providing ventilation whenever possible.

The EPA ranks indoor radon among the most serious environmental health problems facing us today. After smoking, it is the second leading cause of lung cancer in the United States causing an estimated fourteen thousand (14,000) lung cancer deaths a year. Radon is a naturally occurring gas that may seep into buildings from the surrounding soil. In some cases, well water may be a source of radon. You cannot see, taste, or smell radon. In fact, the only way to discover if high levels of radon are present is by testing.

Carbon monoxide is produced by the incomplete combustion of carbon materials; any flame or combustion device is likely to emit carbon monoxide. Carbon monoxide may be present in auto shops, home economics or other kitchen rooms, or in rooms that take in air from areas where buses or other vehicles idle. Carbon monoxide can get trapped inside an area when: appliances do not work properly; a stove or furnace is not working properly due to a clogged chimney or vent; a car or bus is left running in an enclosed space or near an air intake area; or a charcoal grill is used in a closed area (CPSC, 1993).

Carbon monoxide combines with hemoglobin to form carboxyhemoglobin, which is incapable of carrying oxygen, resulting in tissue anoxia. The health threat from exposure to CO is especially serious for those with cardiovascular disease. Healthy individuals may also be affected, but at higher levels of exposure. Early symptoms of exposure include flu-like symptoms (headache, fatigue, nausea). Principle manifestations of acute carbon monoxide poisoning are shortness of breath and a bright red color of mucus membranes (CPSC, 1993).

Mercury is a naturally-occurring element that is present throughout the environment. "Mercury contamination results from exposure through the air, water, food or soil, or through direct contact. Exposure to metallic mercury (as opposed to methylmercury that is ingested) occurs when it is not stored in a closed container. Contamination may include the spilling of metallic mercury on clothes, furniture, carpets, floors, walls, the natural environment, and even the human body. Metallic mercury and its vapors are extremely difficult to remove from items such as clothes, furniture, carpet, floors, and walls. The vapors will also accumulate in walls and other structures in contaminated rooms. The contamination can remain for months or years, posing a risk to exposed individuals" (Centers for Disease Control and Prevention, 1997).

"In the human body, mercury accumulates in the liver, kidney, brain, and blood. Mercury may cause acute or chronic health effects. Children exposed to metallic mercury for long periods may have trouble learning in school (Centers for Disease Control, 1997). Mercury is a recognized developmental neurotoxicant linked to mental retardation, gait and visual disturbances, neurological damage, and impairment of language, attention and memory. Repeated exposure to relatively low toxic levels can cause muscle tremor, irritability, personality changes or gingivitis." ( Reeder, R., 1995, p.2) Acute exposure (i.e., short term, high dose) is not common today due to greater precautions and decreased handling. However, acute effects may include severe gastrointestinal damage, cardiovascular collapse, or kidney failure, all of which could be fatal. Inhalation of 1-3 mg/m3 for 2-5 hours may cause headaches, salivation, metallic taste in the mouth, chills, cough, fever, tremors, abdominal cramps, diarrhea, nausea, vomiting, tightness in the chest, difficulty breathing, fatigue, or lung irritation. Symptoms may be delayed in onset for a number of hours" (Michigan State University, 1996).

The selection of building products, cleaning products, art and science supplies, and many other products that are used in schools can influence the health risks in the school. The use of less toxic products in schools is recommended by many as a zero to low-cost way to help protect indoor air quality in schools. In addition to creating indoor air quality pollution, hazardous chemicals often create pollution during their manufacture and disposal. Some pollute water and air; others must be disposed of as hazardous waste, or cause more harm when their containers are buried in landfills or burned in incinerators (Healthy Schools Network ).

Rubber cement, permanent felt tip markers, pottery glazes, enamels, spray fixatives, and other potentially hazardous materials are sold for use in schools, despite the fact that there are often animal and human studies demonstrating their toxicity. Chemicals used in arts and crafts supplies, and biological and chemical agents used for laboratory sciences, such as formaldehyde, may be toxic. Paints, glues, and other art, science, and vocational supplies contain chemicals that can be toxic to children and pollute the air. Industrial arts courses can expose children to metal dusts, fumes, and wood dust. Chemicals such as acetic acid, aminophenol, ammonia, hydrochloric acid, etc., are found in photo labs that often lack safety equipment and proper ventilation. Kiln firing can release clay dust, which can contain silica (known to cause fibrosis) and toxic gases such as carbon monoxide and heavy metals from the glazes. Home economics and theater exposures may include fabric dyes, oven cleaners, cosmetics, hairsprays, and fog and smoke effects generated from machines using glycols and mineral oil. Copy machines produce ozone that has been linked to lung problems and should be run only in well-ventilated rooms.

Of the 80,000 chemicals in commercial use today, only a very small fraction have been individually tested for toxicity. Unless a chemical is a food, drug, or cosmetic, there are virtually no requirements for complete toxicity testing (animal or human). The 1996 Food Quality Protection Act now requires more extensive testing of pesticides than previously required. Tests on various chemicals acting in combination with one another are practically non-existent. Despite this, a wide variety of toxic or hazardous products are routinely used in buildings. Schools are no different, except the majority of school occupants are children packed very close together. Nurses or facility managers should obtain Material Safety Data Sheets (MSDS) for any chemicals used in building. These can be obtained from the chemical manufacturer.

Helpful EPP Websites The Healthy Schools Network offers an 8-page guide on healthier cleaning and maintenance practices and products that promotes "green" housekeeping The Environmental Protection Agency EPP web site Federal Trade Commission provides guidance on the laws interpreting environmental marketing claims Green Seal is an independent, nonprofit organization dedicated to protecting the environment by promoting the manufacture and sale of environmentally responsible consumer products

Nurses who work in school settings and nurses who are parents to children in school settings can play a significant role in affecting the environmental quality of schools. Because there is no single person who can "make" a school environmentally healthy and safe, a good place to start is with a committee of people who may each play a role in improving the school's environment. In many workplaces, health and safety committees provide the structure through which to address conditions that may pose risks to health. Because schools are both workplaces for adults and learning places for children, creating a health and safety committee can provide a forum in which a multidisciplinary team can learn about health and safety issues; develop and exercise assessment capabilities; prioritize concerns and issues; develop an intervention plan; and provide a feedback loop regarding the success of the remediation and other intervention activities. A health and safety committee can also propose policies. Some of the people who could be considered for a school health and safety committee would be teachers, principals, parents, custodial staff, facilities managers, a school board representative, and even a student.

The Environmental Protection Agency has created an action kit entitled Indoor Air Quality Tools for Schools that provides a complete program that schools can implement to assess and address indoor air quality concerns. To obtain a kit at no cost, call the EPA clearing house at (800) 438-4318.

Some of the issues that should be addressed when considering the development of a health and safety committee in a school include: Who will chair the meetings? Will the group elect a chair? Will it be a member of the school's management? Should it be shared by a parent, employee, and principal (or other manager)? Should facilitation of the meetings be rotated? Who will take notes and how will they be distributed? How often will the committee meet, for how long, and where? Will you include facilities "walk-through" as part of your meeting? Every meeting? Once a problem is identified and an intervention suggested, who is responsible for its implementation? What is the recourse of the committee if the intervention is not implemented? What is the appropriate mechanism for communicating to the whole school and parent community when a problem has been identified or any other finding or decisions of the committee, including recommendations for actions?

A Healthy and Safe Nurse's Office What a nurse can do in his or her immediate domain: Eliminate the mercury thermometers and mercury blood pressure cuffs. Replace them with non-mercury ones. (Make sure that the mercury containing ones are disposed of properly because they are considered hazardous waste.) See www.noharm.org Eliminate latex-containing products, particularly latex gloves. Many children and adults are allergic to latex. See ANA's latex web site. Request that the health suite NOT be routinely sprayed with pesticides, especially if your school has a regularly scheduled pesticide application. Employ IPM techniques if pests are noted. See: www.childproofing.org/poisonedschoolsmain.html Check the ventilation in the health suite. Are the vents free from obstruction? Do you know where the "fresh air" intake is located? Check to make sure that the intake is in a location that is as healthy as possible. See: www.epa.gov/iaq/schools/tfs/guide5.html. If there are any signs of moisture problems, request that maintenance repair the problem. Check to see if there is lead-based paint in your suite. Since sick students and staff frequent the health office, it is important to take steps that can help prevent transmission of airborne diseases. Ensure that the ventilation system is properly operating. See that air filters are clean and properly installed. Question whether air removed from the health suite circulates through the ventilation system into other occupied areas. If so, request that this situation be addressed. Obtain Material Safety Data Sheets (MSDS) for any chemicals used in building from the chemical manufacturer.

Nurses are becoming increasingly involved in environmental health issues. In this article, some of the key environmental health risks found inside schools have been presented, including pesticides, mercury, asthma triggers, formaldehyde, and carbon monoxide. Children's special vulnerabilities to environmental exposures were explored, especially as they pertain to the school-aged children. Nursing actions to reduce environmental exposures in schools were outlined, including directions for creating an environmentally-healthy nursing suite. Additionally, guidance was provided regarding collective action and advocacy through the creation of and participation in environmental health and safety committees.