Amy Wolkin

Associations between Polybrominated Diphenyl Ether (PBDE) Flame Retardants, Phenolic Metabolites, and Thyroid Hormones during Pregnancy

Background: Polybrominated diphenyl ethers (PBDEs) are chemical additives used as flame retardants in commercial products. PBDEs are bioaccumulative and persistent and have been linked to several adverse health outcomes. Objectives: This study leverages an ongoing pregnancy cohort to measure PBDEs and PBDE metabolites in serum collected from an understudied population of pregnant women late in their third trimester. A secondary objective was to determine whether the PBDEs or their metabolites were associated with maternal thyroid hormones. Methods: One hundred forty pregnant women > 34 weeks into their pregnancy were recruited into this study between 2008 and 2010. Blood samples were collected during a routine prenatal clinic visit. Serum was analyzed for a suite of PBDEs, three phenolic metabolites (i.e., containing an –OH moiety), and five thyroid hormones. Results: PBDEs were detected in all samples and ranged from 3.6 to 694 ng/g lipid. Two hydroxylated BDE congeners (4´-OH-BDE 49 and 6-OH-BDE 47) were detected in > 67% of the samples. BDEs 47, 99, and 100 were significantly and positively associated with free and total thyroxine (T4) levels and with total triiodothyronine levels above the normal range. Associations between T4 and PBDEs remained after controlling for smoking status, maternal age, race, gestational age, and parity. Conclusions: PBDEs and OH-BDEs are prevalent in this cohort, and levels are similar to those in the general population. Given their long half-lives, PBDEs may be affecting thyroid regulation throughout pregnancy. Further research is warranted to determine mechanisms through which PBDEs affect thyroid hormone levels in developing fetuses and newborn babies.

Serum Concentrations of Selected Persistent Organic Pollutants in a Sample of Pregnant Females and Changes in Their Concentrations during Gestation

Objectives In this study we evaluated the concentrations of selected persistent organic pollutants in a sample of first-time pregnant females residing in the United States and assessed differences in these concentrations in all pregnant females during gestation. Methods We reviewed demographic and laboratory data for pregnant females participating in the National Health and Nutrition Examination Survey, including concentrations of 25 polychlorinated biphenyls (PCBs), 6 polychlorinated dibenzo-p-dioxins (PCDDs), 9 polychlorinated dibenzofurans (PCDFs), and 9 organochlorine pesticides. We report serum concentrations for first-time pregnant females (2001–2002; n = 49) and evaluate these concentrations in all pregnant females by trimester (1999–2002; n = 203) using a cross-sectional analysis. Results The chemicals with ≥ 60% detection included PCBs (congeners 126, 138/158, 153, 180), PCDDs/PCDFs [1,2,3,4,6,7,8-heptachlorodibenzo-p-dioxin (1234678HpCDD), 1,2,3,6,7,8-hexachlorodibenzo-p-dioxin (123678HxCDD), 1,2,3,4,6,7,8-heptachlorodibenzofuran (1234678HpCDF), 1,1′-(2,2-dichloroethenylidene)-bis(4-chlorobenzene) (p,p′-DDE)], and trans-nonachlor. The geometric mean concentration (95% confidence intervals) for 1234678HpCDD was 15.9 pg/g lipid (5.0–50.6 pg/g); for 123678HxCDD, 9.7 pg/g (5.5–17.1 pg/g); and for 1234678HpCDF, 5.4 pg/g (3.3–8.7 pg/g). The differences in concentrations of these chemicals by trimester were better accounted for with the use of lipid-adjusted units than with whole-weight units; however, the increase in the third-trimester concentration was greater for PCDDs/PCDFs (123678HxCDD, 1234678HpCDF) than for the highest concentration of indicator PCBs (138/158, 153, 180), even after adjusting for potential confounders. Conclusion The concentrations of these persistent organic pollutants in a sample of first-time pregnant females living in the United States suggest a decline in exposures to these chemicals since their ban or restricted use and emission. The redistribution of body burden for these and other persistent organic pollutants during pregnancy needs to be more carefully defined to improve the assessment of fetal exposure to them based on maternal serum concentrations. Additional studies are needed to further the understanding of the potential health consequences to the fetus from persistent organic pollutants.

The role of applied epidemiology methods in the disaster management cycle

Disaster epidemiology (i.e., applied epidemiology in disaster settings) presents a source of reliable and actionable information for decision-makers and stakeholders in the disaster management cycle. However, epidemiological methods have yet to be routinely integrated into disaster response and fully communicated to response leaders. We present a framework consisting of rapid needs assessments, health surveillance, tracking and registries, and epidemiological investigations, including risk factor and health outcome studies and evaluation of interventions, which can be practiced throughout the cycle. Applying each method can result in actionable information for planners and decision-makers responsible for preparedness, response, and recovery. Disaster epidemiology, once integrated into the disaster management cycle, can provide the evidence base to inform and enhance response capability within the public health infrastructure.

Associations between serum levels of Polybrominated Diphenyl Ether (PBDE) flame retardants and environmental and behavioral factors in pregnant women

Polybrominated diphenyl ethers (PBDE) are flame retardants that were previously used in upholstery, fabrics, and household appliances. PBDEs have been linked to adverse health outcomes, including neurotoxicity, thyroid hormone dysregulation, endocrine disruption, and poor semen quality. Because PBDEs pass into placental circulation, maternal exposures can approximate fetal exposures. Our objectives were to determine whether diet and specific human behaviors were significantly associated with PBDE exposures in a cohort of pregnant women. Women between the 34th and 38th week of pregnancy were given a questionnaire about behavioral, environmental, and dietary factors and asked to provide blood samples. Serum PBDE levels were measured using GS-MS and lipid adjusted. An adjusted ordinary least squares regression model was run to identify potential associations between behaviors and serum PBDE levels. Serum concentrations of BDEs 47, 99, 100, and 153 were found above the limit of detection in at least 50% of study participants and used in our models. Associations with serum PBDEs were observed with self-reported hand-to-mouth behaviors, including biting nails and licking fingers. Serum BDE levels of 47, 99, 153, and total PBDEs were also significantly higher in those individuals owning a large-screen TV compared with those who did not. Serum PBDE levels were comparable to levels reported in the general population. Hand-to-mouth behaviors may influence serum PBDE concentrations in adults. Household electronics such as large-screen TVs appear to serve as a significant source of PBDEs in pregnant women. Together, hand-to-mouth behaviors and TV ownership may serve as a route of exposure to PBDEs in adults.

Mental Health Needs Assessment After the Gulf Coast Oil Spill—Alabama and Mississippi, 2010

INTRODUCTION Previous oil spills and disasters from other human-made events have shown that mental health effects to the affected population are widespread and can be significant. HYPOTHESIS/PROBLEM There has been concern regarding the likelihood that existing public health surveillance was not capturing the mental health effects to the population affected by the Gulf Coast oil spill. The objectives of this study were to assess the mental health needs of coastal communities in the states of Alabama and Mississippi following the Deepwater Horizon oil spill. METHODS A cluster sampling methodology was used to assess the mental health status of coastal residents in three counties in Alabama four months following the 2010 Deepwater Horizon oil spill, and in the Gulf Coast counties in Mississippi 5.5 months after the oil spill. RESULTS A total of 469 residents of the selected areas were interviewed. Between 15.4 and 24.5% of the respondents reported depressive symptoms, with 21.4-31.5% reporting symptoms consistent with an anxiety disorder, and 16.3-22.8% reporting ≥14 mentally unhealthy days within the past 30 days. Overall, there were more negative quality of life indicators and negative social context outcomes than in the states Behavioral Risk Factor Surveillance System (BRFSS) survey. Between 32.1% and 35.7% of all households reported decreased income since the oil spill, and 35.5-38.2% of all households reported having been exposed to oil. CONCLUSION The proportion of respondents reporting negative mental health parameters in the affected Alabama and Mississippi coastal communities is higher than the proportion reported in the 2008 and 2009 BRFSS state reports, suggesting that the public health response to the Deepwater Horizon oil spill should focus on mental health services in these communities.

Community Assessment for Public Health Emergency Response (CASPER) one year following the Gulf Coast oil spill: Alabama and Mississippi, 2011.

BACKGROUND On April 20, 2010, the Deepwater Horizon drilling unit exploded off the coast of Louisiana, resulting in 11 deaths and the largest marine petroleum release in history. Previous oil spill disasters have been associated with negative mental health outcomes in affected communities. In response to requests from Mississippi and Alabama, potential mental health issues resulting from this event were identified by implementing a novel use of a Community Assessment for Public Health Emergency Response (CASPER) in the months immediately following the Gulf Coast oil spill. PURPOSE This assessment was repeated one year later to determine long-term mental health needs and changes. METHODS A two-stage sampling method was used to select households, and a questionnaire including the Centers for Disease Control and Preventions Behavioral Risk Factor Surveillance System (BRFSS) questions was administered. Weighted cluster analysis was conducted, and BRFSS questions were compared to the most recent BRFSS reports and the 2010 results. RESULTS In 2011, 8.8%-15.1% of individuals reported depressive symptoms compared to 15.4%-24.5% of individuals in 2010, with 13.2%-20.3% reporting symptoms consistent with an anxiety disorder compared to 21.4%-31.5% of individuals in 2010. Respondents reporting decreased income following the oil spill were more likely to report mental health symptoms compared to respondents reporting no change in income. CONCLUSIONS Overall, mental health symptoms were higher in the three assessment areas compared to BRFSS reports, but lower than 2010 surveys. These results suggest that mental health services are still needed, particularly in households experiencing decreased income since the oil spill.

Perchlorate exposure from infant formula and comparisons with the perchlorate reference dose

Perchlorate exposure may be higher in infants compared with older persons, due to diet (infant formula) and body weight versus intake considerations. Our primary objective was to quantitatively assess perchlorate concentrations in commercially available powdered infant formulas (PIFs). Secondary objectives were: (1) to estimate exposure in infants under different dosing scenarios and compare them with the perchlorate reference dose (RfD); (2) estimate the perchlorate concentration in water used for preparing PIFs that would result in a dose exceeding the RfD; and (3) estimate iodine intakes from PIFs. We quantified perchlorate levels in three samples (different lot numbers) of reconstituted PIF (using perchlorate-free water) from commercial brands of PIF in each of the following categories: bovine milk-based with lactose, soy-based, bovine milk-based but lactose-free, and elemental (typically consisting of synthetic amino acids). Exposure modeling was conducted to determine whether the RfD might be exceeded in 48 dosing scenarios that were dependent on age, centile energy intake per unit of body weight, body weight percentile, and PIF perchlorate concentration. We obtained three different samples in each of the five brands of bovine- and soy-based PIF, three different samples in each of the three brands of lactose-free PIF, and three different samples in two brands of elemental PIF. The results were as follows: bovine milk-based with lactose (1.72 μg/l, range: 0.68–5.05); soy-based (0.21 μg/l, range: 0.10–0.44); lactose-free (0.27 μg/l, range: 0.03–0.93); and elemental (0.18 μg/l, range: 0.08–0.4). Bovine milk-based PIFs with lactose had a significantly higher concentration of perchlorate (P<0.05) compared with all. Perchlorate was a contaminant of all commercially available PIFs tested. Bovine milk-based PIFs with lactose had a significantly higher perchlorate concentration perchlorate than soy, lactose-free, and elemental PIFs. The perchlorate RfD may be exceeded when certain bovine milk-based PIFs are ingested and/or when PIFs are reconstituted with perchlorate-contaminated water.

Severe Illness Associated with Reported Use of Synthetic Cannabinoids - Mississippi, April 2015.

On April 2, 2015, four patients were evaluated at the University of Mississippi Medical Center (UMMC) in Jackson, Mississippi, for agitated delirium after using synthetic cannabinoids. Over the next 3 days, 24 additional persons went to UMMC with illnesses suspected to be related to synthetic cannabinoid use; one patient died. UMMC notified the Mississippi State Department of Health, which issued a statewide alert via the Health Alert Network on April 5, requesting that health care providers report suspected cases of synthetic cannabinoid intoxication to the Mississippi Poison Control Center (MPCC). A suspected case was defined as the occurrence of at least two of the following symptoms: sweating, severe agitation, or psychosis in a person with known or suspected synthetic cannabinoid use. A second statewide alert was issued on April 13, instructing all Mississippi emergency departments to submit line lists of suspected patients to MPCC each day. By April 21, 16 days after the first alert was issued, MPCC had received reports of approximately 400 cases, including eight deaths possibly linked to synthetic cannabinoid use; in contrast, during April 2012–March 2015, the median number of telephone calls to MPCC regarding synthetic cannabinoid use was one per month (range = 0–11). The Mississippi State Department of Health, with the assistance of CDC, initiated an investigation to better characterize the outbreak, identify risk factors associated with severe illness, and prevent additional illnesses and deaths.

Tracking deaths related to Hurricane Ike, Texas, 2008.

BACKGROUND On September 13, 2008, Hurricane Ike, a category 2 storm with maximum sustained winds of 110 mph, made landfall near Galveston, Texas. Ike produced a damaging, destructive, and deadly storm surge across the upper Texas and southwestern Louisiana coasts. Thirty-four Texas counties were declared disaster areas by the Federal Emergency Management Agency; 15 counties were under mandatory evacuation orders. To describe causes of death associated with this hurricane and identify prevention strategies during the response and recovery phases, the Texas Department of State Health Services (DSHS) monitored mortality data in 44 counties throughout the state. This report summarizes Ike-related deaths reported by Texas medical examiners, justices of the peace (coroners), forensic centers, public health officials, and hospitals. METHODS Based on the Centers for Disease Control and Prevention (CDC) disaster-related mortality surveillance form, DSHS developed a state-specific 1-page form and collected (optimally daily) data on demographic, date and place of death, and cause and circumstance of deaths. A case was defined as any death that was directly or indirectly related to Ike among evacuees, residents, nonresidents, or rescue personnel in the declared disaster counties, counties along the Texas Gulf coast or counties known to have evacuation shelters occurring September 8, 2008, through October 13, 2008. Analyzed data were shared with the state emergency operation center and the CDC on a daily basis. RESULTS The surveillance identified 74 deaths in Texas as directly (10 [14%]), indirectly (49 [66%]), or possibly (15 [20%]) related to Ike. The majority of deaths (n=57) were reported by medical examiners. Deaths occurred in 16 counties of the 44 counties covered by the surveillance. The majority of deaths occurred in Harris and Galveston (28 [38%] and 17 [23%]), respectively. The deceased ranged in age from younger than 1 year to 85 years, with an average age of 46 years (median 50 years); 70% were male. Of the 74 deaths, 47 (64%) resulted from injuries, 23 (31%) from illnesses, and 4 (5%) were undetermined. Among the injuries, carbon monoxide poisoning (13 [18%]) and drowning (8 [11%]) were the leading causes of injury-related deaths. Cardiovascular failure (12 [16%]) was the leading cause of illness-related deaths. CONCLUSIONS Defining the relation of death to hurricane using an active mortality surveillance system is possible. The active mortality surveillance form used in Ike provided valuable daily information to DSHS, state emergency management officials, and the CDC regarding the characteristics of deaths in the state. Most of the Ike-related deaths were caused by injury (direct and indirectly related) such as carbon monoxide poisonings and drowning and may have been preventable by educating the public.

Exertional Heat-Related Illnesses at the Grand Canyon National Park, 2004–2009

BACKGROUND The Grand Canyon National Park has approximately 4 million visitors between April and September each year. During this period, outdoor activity such as hiking is potentially hazardous owing to extreme heat, limited shade, and steep, long ascents. Given the high visitation and the public health interest in the effects of extreme heat, this study calculated morbidity rates and described heat-related illness (HRI) among visitors. METHODS We conducted a retrospective cross-sectional study from April 1 through September 30, during 2004-2009. From a review of Ranger Emergency Medical Services (EMS) incident report files, we extracted information on those that met the case definition of greater than 1 hour of outdoor heat exposure with an HRI assessment or diagnosis, HRI self-report, or signs or symptoms of HRI without another etiology noted. Visitor and temperature data were obtained from respective official sources. RESULTS Grand Canyon EMS responded to 474 nonfatal and 6 fatal HRI cases, with the majority (84%) being US residents, 29% from Western states. Of the nonfatal cases, 51% were women, the median age was 43 years (range, 11-83 years), and 18% reported a cardiovascular condition. Clinical HRI assessments included dehydration (25%), heat exhaustion (23%), and suspected hyponatremia (19%). Almost all (90%) were hiking; 40% required helicopter evacuation. The highest HRI rates were seen in May. CONCLUSIONS HRI remains a public health concern at the Grand Canyon. High-risk evacuations and life-threatening conditions were found. Majority were hikers, middle-aged adults, and US residents. These findings support the parks hiker HRI prevention efforts and use of park EMS data to measure HRI.