Who helps to protect us in the event of an environmental emergency?

Medical toxicologists. This not widely known medical subspecialty, comprised of physicians, focuses on the diagnosis, management, and prevention of poisoning and other adverse health effects resulting from medications, occupational and environmental poisons, and biological agents (bacteria, virus, parasite, or fungus, for example) that can be used as bioterrorism or biological weapons. It is one of many professions that help protect us during an environmental health emergency.

The path to public health

Meet Dr. Josh Schier, medical toxicologist at CDCs National Center for Environmental Health (NCEH). “I always wanted to work at CDC and get into public health, but I didn’t know exactly how that was going to happen,” says Josh.

Born in Philadelphia, PA, Josh went to Widener University and majored in biology. He then went to Temple University School of Medicine, graduating in 1998, and completed a residency in emergency medicine in 2001 at Cooper University Hospital. He completed a fellowship in medical toxicology at the New York University School of Medicine in 2003, and obtained a Master of Public Health in epidemiology in 2012.

“After I finished my medical toxicology fellowship, one of the residents who was training at the emergency medicine residency program where my medical toxicology fellowship was based happened to mention that CDC was looking for full-time medical toxicologists,” Josh explains. “I thought that would be an incredible opportunity, so I put my name in.”

Josh began work at CDC in 2003 as a United States Public Health Services Commissioned Corps Officer in NCEH’s, Division of Environmental Hazards and Health Effects, Health Studies Branch (HSB). “One of my first assignments had to do with chemical terrorism preparedness issues, as well as toxicological health questions that came up.” Since that time, Josh has become the team lead for HSB’s Environmental Toxicology Team, which operates and directs several toxicology programs for HSB including a national surveillance program using poison center data. The team also provides subject matter expertise in medical toxicology for environmental health issues (e.g., outbreaks, public health investigations, preparedness work and others) and trains physicians in medical toxicology and public health practice.

The nation’s poison center surveillance network

Josh’s current work involves working very closely with poison centers throughout the U.S. to conduct public health surveillance on clusters of illness and events of potential public health significance. Throughout the U.S. and its territories, 55 poison centers answer calls from the public and health care practitioners about possible hazardous exposures. Poison center staff also answer general questions and basic requests for information about chemicals and other agents. Each poison center stores this information locally, and every 8 minutes much of it gets uploaded to the National Poison Data System. This system is not only a national poison center reporting database but also an electronic, near real-time surveillance system.

The American Association of Poison Control Centers (AAPCC) manages the National Poison Data System, and CDC works very closely with AAPCC for its national surveillance activities. CDC uses National Poison Data System data in three different ways:

1. To conduct routine surveillance for clusters of calls about potentially hazardous exposures and illnesses, as well as calls about specific exposures and illnesses of interest to CDC such as terrorism agents.
2. To use for case finding activities and situational awareness during large suspected or known threats (i.e., oil exposures from oil spills such as the Deepwater Horizon incident or carbon monoxide exposures from hurricanes (i.e., Hurricane Sandy).
3. To study emerging environmental health threats such as adverse health effects related to synthetic cannabinoids use, laundry detergent pod exposures in children, and e-cigarette exposures. All of these studies resulted in published MMWRs:
   • Increase in Reported Adverse Health Effects Related to Synthetic Cannabinoid Use — United States, January–May 2015
   • Health Hazards Associated with Laundry Detergent Pods – United States, May-June 2012
   • Calls to Poison Centers for Exposures to Electronic Cigarettes — United States, September 2010–February 2014

When routine surveillance activities detect any sort of poison center data inconsistency (see #1), a team of AAPCC toxicologists receives an alert. They determine if the data meet pre-specified criteria for potential public health significance. If yes, the team notifies CDC and if necessary, contacts the appropriate state health department and poison center where the call(s) originated.

Inspiring the next generation of medical toxicologists

Josh currently serves as associate director of one of the most public-health-focused medical toxicology training programs in the United States: Emory University and CDC’s Medical Toxicology Fellowship Program.

Fellows work with medical toxicologists at CDC’s NCEH/ATSDR to investigate various outbreaks of illness both nationally and internationally. They work hand-in-hand with epidemiologists and laboratorians at CDC and partner institutions (often state health departments or foreign ministries of health) investigating public health threats like a recent mass poisoning in Mozambique that was the result of beer contaminated with a microbial toxin.

Another recent event took place in Mississippi, where CDC assisted the state health department there in an investigation examining the adverse effects of an outbreak of illness resulting from synthetic cannabinoid use. This work resulted in a CDC and ATSDR annual honor award for NCEH/ATSDR’s Synthetic Cannabinoid Investigation Team for its exemplary application of epidemiologic principles and methods to the study of adverse events associated with synthetic cannabinoid use. Medical toxicology aided this epidemiological work.

Providing a medical voice for environmental health issues, Josh inspires physicians who otherwise would choose very academic clinical careers to get involved in public health. These physicians go on to learn about public-health-related issues and apply their skills at local, state, or federal levels.

Passionate about medical toxicology, public health, and good health in general

Married in 2000, and the father of two children, a 10 year old girl and a 6 year old boy, Josh is passionate about his family (including a dog – a King Charles Cavalier – named Merlin). He believes strongly that physical fitness is vital to overall well-being and exercises four to five times per week with CrossFit-style workouts.

Josh’s passion about medical toxicology and what it brings to public health, paralleling infectious disease, is clear. Just as physicians who are clinically trained in infectious disease are well-suited to help in infectious disease related public health issues (typhoid, HIV, etc.) physicians trained in medical toxicology are well suited to helping and working in environmental health.

He believes that this relatively young but growing specialty is one of the best and most appropriate specialties for medical-related environmental health preparedness and research.

Additional Resources:

Poison Center Surveillance Activities: http://www.cdc.gov/nceh/hsb/chemicals/ncrs.htm

Emory/CDC’s Medical Toxicology Fellowship Program: http://em.emory.edu/education/fellowship/medical_toxicology.html

Need help?

American Association of Poison Control Centers

United States: 1 (800) 222-1222
Hours: 24 hours a day, 7 days a week
Website: www.aapcc.org