ADVANCEMENT OF THE SCIENCE
with increasing levels of exposure in individ- uals (Han et al., 2010, 2011; Polettini et al., 2012; Wright et al., 2020). Higher concen- trations of methamphetamine were found in segmented hair sections compared with con- centrations found using an external hair wash solution, indicating the dierence between drugs settled on the outside of hair and drugs incorporated into the hair matrix by means of ingestion (Kintz, 2017; Kintz et al., 2020). In addition, variation in concentrations from the root to the tip of the hairs demonstrated that the hair matrix captured the drug as the hair matrix grew, and that the contamination var- ied over a period of time (Kintz et al., 2021). Syndromes and Acronyms Establishment of a defined term to describe the health consequences of thirdhand expo- sure to methamphetamine is needed to raise awareness, facilitate data collection, improve diagnoses, and encourage future research into potential long-term health consequences. Calvo et al. (2003) defined a syndrome as a group of known symptoms that can be attributed to a specific illness, even when the complete associations for that ailment might not be fully established. Other syndromes have been defined and given an acronym for future identification in research. For exam- ple, chronic fatigue syndrome (CFS; Brurberg et al., 2014), irritable bowel syndrome (IBS; Chey et al., 2015), and sick building syn- drome (SBS; Redlich et al., 1997) are a few syndrome classifications with a number of nonspecific symptoms. SBS has a number of similarities to third- hand exposure to methamphetamine, and thus we described it in some detail. In the 1980s, the World Health Organization char- acterized SBS as a combination of symptoms that are expressed through multiple organ systems when people are exposed to an en- closed built structure, such as an oce build- ing, hospital, or school (Redlich et al., 1997; Runeson-Broberg, 2020). Similar to exposure to methamphetamine, the symptoms are nonspecific. Individuals reported headaches, lethargy, itchy and watery eyes, nasal conges- tion, and skin irritation—symptoms that are commonly associated with other illnesses (Burge, 2004). Several factors have been doc- umented that increase the prevalence of SBS within a cohort including allergies, sex, tem- perature, ventilation, outdoor air pollution,
and volatile organic compounds (Mentese et al., 2020; Runeson-Broberg, 2020; Saijo, 2020). Overall, SBS highlights the range of indoor air quality conditions and how symp- toms can vary in individuals. As such, like SBS, it is reasonable to pre- sume there are some members of the public who have not reported adverse health issues or who have reported them but have attribut- ed them to another illness (Runeson-Broberg, 2020). Exposure levels are dependent on the individual’s risk factors, activities, and expo- sure times (Kintz et al., 1995; Tsanaclis & Wicks, 2008; Wright et al., 2020). In conjunc- tion with self-reported symptoms, however, exposure to amphetamine-type stimulant contamination can be verified by quantitative sampling of blood, urine, hair, and the per- son’s environment (Kintz et al., 1995; Tsana- clis & Wicks, 2008). We propose THEM syndrome as a name for the range of adverse health eects experienced by individuals due to contamination from amphetamine-type stimulants, specifically methamphetamine. Current Situation Research has established that there has been an increase in autopsies of infants and chil- dren with methamphetamine present in their systems (Kenneally & Byard, 2020; Tse et al., 2020). There were seven case studies identi- fied by forensic scientists in South Australia and eight from New Zealand (Kenneally & Byard, 2020; Tse et al., 2020). Of these 15 cases, 6 out of 7 (86%) from South Austra- lia and 8 out of 8 (100%) from New Zealand were for infants under the age of 12 months. Using blood analysis, both studies deter- mined that there was no deliberate ingestion and there was a known cause of death for all except two of the cases from South Australia. Thus, these infants were exposed passively either in utero, from breastmilk or formula, or via environmental exposure (Kenneally & Byard, 2020; Tse et al., 2020). There have been several other studies that investigated methamphetamine exposure in children (Castaneto et al., 2013; Flannery et al., 2006; Kintz et al., 1995; Tsanaclis & Wicks, 2008; Wright et al., 2020); however, future research is needed to determine the health burden of thirdhand exposure. This situation regarding thirdhand expo- sure is exacerbated by a housing shortage in many countries worldwide (Brill & Raco,
2021; Lima, 2021; Massimo, 2021; Richard- son, 2022). As a result, sometimes housing is rented or sold without sucient inspection (Ullah & Sepasgozar, 2020). Additionally, due to privacy laws, a detailed account about a property’s illicit drug history is not available even after law enforcement was involved. In Australia, it is estimated that only 1 in 10 clan- destine laboratories are discovered, meaning many go undetected (Degenhardt et al., 2017) and rarely, if ever, is a house investigated due to methamphetamine use alone. In summary, the turbulent housing market might poten- tially result in an increase in THEM syndrome. Furthermore, with the increase in roadside random drug testing and workplace testing for illicit drugs (Bade et al., 2018; Love et al., 2022; Mills et al., 2021; Smith et al., 2021), there are other unintended consequences of THEM syndrome. Residents who are exposed to methamphetamine contamination poten- tially could run the risk of testing positive in a workplace drug test (Buzby et al., 2021; Kapur & Aleksa, 2020; Tremonti & Haber, 2021), which would have numerous social and physi- ological consequences. This issue is further complicated by the potential for THEM syn- drome to occur because of where an individ- ual works; examples include police ocers or social workers who unknowingly enter con- taminated properties (Hannan, 2005; Norman et al., 2021; Witter et al., 2007). Recommendations for the Environmental Health Profession The environmental health profession is pro- foundly local (Rodrigues et al., 2021). Envi- ronmental health professionals work on the front line to protect public health and can be the first point of contact for individuals who are concerned about methamphetamine-con- taminated properties (Kuhn, Walker, Wright, et al., 2021). The environmental health pro- fession is best positioned to take on the chal- lenge of regulating this public health threat. Currently, however, there are many busi- nesses working in this space. In Australia, it has been found that there is a concerning lack of industry regulation and additionally, some businesses have been found to have conflicts of interest (Kuhn, Walker, Whiley, et al., 2021). For example, some companies have been conducting the initial testing for a property, the decontamination process, and then also the validation testing to confirm
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Volume 86 • Number 3
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