Andrew E. Smith

Awake at the switch: Improving fish consumption advisories for at-risk women

Eating fish provides health benefits; however, nearly all fish contain at least some methylmercury which can impair human health. While government agencies have been issuing fish consumption advisories for 40 years, recent evaluation efforts highlight their poor performance. The benefit of an advisory can be measured by its ability to inform consumers as to both the positive and negative attributes of their potential choices, leading to appropriate changes in behavior. Because of the health benefits, fish advisories should not reduce fish consumption, even among at-risk individuals, but should lead consumers to switch away from highly contaminated fish toward those less contaminated. Although studies document how advisories reduce fish consumption (a negative outcome), no study indicates whether they lead to switching behavior (a positive outcome). We explore the effects of Maine Center of Disease Control and Preventions advisory aimed at informing women who may become pregnant, nursing mothers and pregnant women about the benefits and risks of fish consumption. We examine how the advisory changes consumption, especially related to switching behavior. We demonstrate such changes in behavior both during and after pregnancy and compare the advisory-induced changes with those induced by other information sources. Although we find the advisory reduced some womens consumption of fish, we find the decrease is short-lived. Most importantly, the advisory induced appropriate switching behavior; women reading the advisory decreased their consumption of high-risk fish and increased their consumption of low-risk fish. We conclude a well-designed advisory can successfully transform a complex risk/benefit message into one that leads to appropriate knowledge and behavioral changes.

Carbon monoxide: the case for environmental public health surveillance.

Judith M. Graber, MSa Steven C. Macdonald, PhD, MPHb Daniel E. Kass, MSPHC Andrew E. Smith, SM, ScDa Henry A. Anderson, MDd Carbon monoxide is a common, potentially lethal gas produced by the incom plete combustion of fossil fuels such as natural or liquefied petroleum gas, oil, wood, and coal. It is one of the oldest documented toxicants. Mortality and morbidity from acute, unintentional, non-fire-related carbon monoxide poi soning is a substantial, but often unrecognized, public health problem in the United States. (Intentional and fire-related carbon monoxide poisoning have other public health pathways for surveillance, prevention, and control; these events are, therefore, not addressed in this article.) It is estimated that each year in the United States at least 15,200 individuals seek medical attention in an emergency department or miss at least one day of work due to carbon mon oxide poisoning.1 However, this estimate does not account for the full burden of illness; the toxic effects of carbon monoxide exposure are nonspecific and easily misdiagnosed. Symptoms may include headache, dizziness and nausea, and?at higher levels of exposure?disorientation, unconsciousness, and death. The estimate also does not account for those directly admitted to a hospital, those presenting to other types of outpatient clinics, who call poison control centers, who do not seek care, or those who die immediately from carbon monoxide exposure and receive no medical care. Carbon monoxide poisoning occurs both as the result of routine domestic, occupational, and recreational activities, and in the wake of large-scale disasters such as those caused by hurricanes,2,3 floods,4 and winter storms.5 6 It is almost entirely preventable by the correct installation, maintenance, and operation of devices that may emit carbon monoxide, combined with the appropriate use of carbon monoxide detectors (also called carbon monoxide alarms). It has been estimated that carbon monoxide detectors could prevent at least half of all deaths attributable to nondisaster-related carbon monoxide poisoning.7 In 2004, six states (Alaska, Delaware, Florida, Maine, Mississippi, and Montana)

Arsenic in private well water part 3 of 3: Socioeconomic vulnerability to exposure in Maine and New Jersey

Arsenic is a naturally occurring toxic element often concentrated in groundwater at levels unsafe for human consumption. Private well water in the United States is mostly unregulated by federal and state drinking water standards. It is the responsibility of the over 13 million U.S. households regularly depending on private wells for their water to ensure it is safe for drinking. There is a consistent graded association with health outcomes at all levels of socioeconomic status (SES) in the U.S. Differential exposure to environmental risk may be contributing to this persistent SES-health gradient. Environmental justice advocates cite overwhelming evidence that income and other SES measures are consistently inversely correlated with exposure to suboptimal environmental conditions including pollutants, toxins, and their impacts. Here we use private well household surveys from two states to investigate the association between SES and risks for arsenic exposure, examining the potentially cumulative effects of residential location, testing and treatment behavior, and psychological factors influencing behavior. We find that the distribution of natural arsenic hazard in the environment is socioeconomically random. There is no evidence that higher SES households are avoiding areas with arsenic or that lower SES groups are disproportionately residing in areas with arsenic. Instead, disparities in exposure arise from differing rates of protective action, primarily testing well water for arsenic, and secondly treating or avoiding contaminated water. We observe these SES disparities in behavior as well as in the psychological factors that are most favorable to these behaviors. Assessment of risk should not be limited to the spatial occurrence of arsenic alone. It is important that social vulnerability factors are incorporated into risk modeling and identifying priority areas for intervention, which should include strategies that specifically target socioeconomically vulnerable groups as well as all the conditions which cause these disparities in testing and treatment behavior.

Uranium and Radon in Private Bedrock Well Water in Maine: Geospatial Analysis at Two Scales

In greater Augusta of central Maine, 53 out of 1093 (4.8%) private bedrock well water samples from 1534 km2 contained [U] >30 μg/L, the U.S. Environmental Protection Agency’s (EPA) Maximum Contaminant Level (MCL) for drinking water; and 226 out of 786 (29%) samples from 1135 km2 showed [Rn] >4,000 pCi/L (148 Bq/L), the U.S. EPA’s Alternative MCL. Groundwater pH, calcite dissolution and redox condition are factors controlling the distribution of groundwater U but not Rn due to their divergent chemical and hydrological properties. Groundwater U is associated with incompatible elements (S, As, Mo, F, and Cs) in water samples within granitic intrusions. Elevated [U] and [Rn] are located within 5–10 km distance of granitic intrusions but do not show correlations with metamorphism at intermediate scales (100−101 km). This spatial association is confirmed by a high-density sampling (n = 331, 5–40 samples per km2) at local scales (≤10–1 km) and the statewide sampling (n = 5857, 1 sample per 16 km2) at regional scales (102–103 km). Wells located within 5 km of granitic intrusions are at risk of containing high levels of [U] and [Rn]. Approximately 48 800–63 900 and 324 000 people in Maine are estimated at risk of exposure to U (>30 μg/L) and Rn (>4000 pCi/L) in well water, respectively.

Concentration of metals in blood of Maine children 1–6 years old

Blood lead concentrations are higher in young children than in other age groups, whereas little is known regarding concentrations of other metals in young children. We measured the concentrations of a suite of metals in the blood of children 1–6 years of age, and assessed potential differences by age, season, or region of Maine. We used blood submitted to the Maine State Health and Environmental Testing Laboratory for blood lead analysis to determine the concentrations of arsenic (As), antimony (Sb), cadmium (Cd), manganese (Mn), mercury (Hg), selenium (Se), tin (Sn), and uranium (U) in 1350 children 1–6 years of age. The essential metals Mn and Se were detected in all samples, and As and Sb were detected in >90% of samples. Hg was detected in approximately 60% of samples. U and Cd were less often detected in blood samples, at approximately 30% and 10% of samples, respectively. Sn was not detected in any sample. Concentrations of As, Hg, and Se increased with age, whereas Sb decreased with age. Concentrations also varied by season and region for some though not all metals. Significant pairwise correlations were observed for a number of metals. Blood is a reasonable compartment for measurement of most of these metals in young children. The use of convenience samples provided a cost-effective mechanism for assessing exposure of young children in Maine.

Assessing arsenic exposure in households using bottled water or point-of-use treatment systems to mitigate well water contamination

There is little published literature on the efficacy of strategies to reduce exposure to residential well water arsenic. The objectives of our study were to: 1) determine if water arsenic remained a significant exposure source in households using bottled water or point-of-use treatment systems; and 2) evaluate the major sources and routes of any remaining arsenic exposure. We conducted a cross-sectional study of 167 households in Maine using one of these two strategies to prevent exposure to arsenic. Most households included one adult and at least one child. Untreated well water arsenic concentrations ranged from <10 μg/L to 640 μg/L. Urine samples, water samples, daily diet and bathing diaries, and household dietary and water use habit surveys were collected. Generalized estimating equations were used to model the relationship between urinary arsenic and untreated well water arsenic concentration, while accounting for documented consumption of untreated water and dietary sources. If mitigation strategies were fully effective, there should be no relationship between urinary arsenic and well water arsenic. To the contrary, we found that untreated arsenic water concentration remained a significant (p ≤ 0.001) predictor of urinary arsenic levels. When untreated water arsenic concentrations were <40 μg/L, untreated water arsenic was no longer a significant predictor of urinary arsenic. Time spent bathing (alone or in combination with water arsenic concentration) was not associated with urinary arsenic. A predictive analysis of the average study participant suggested that when untreated water arsenic ranged from 100 to 500 μg/L, elimination of any untreated water use would result in an 8%-32% reduction in urinary arsenic for young children, and a 14%-59% reduction for adults. These results demonstrate the importance of complying with a point-of-use or bottled water exposure reduction strategy. However, there remained unexplained, water-related routes of exposure.

Heat-related morbidity and mortality in New England: Evidence for local policy

Background: Heat‐related morbidity and mortality is a recognized public health concern. However, public health officials need to base policy decisions on local evidence, which is often lacking for smaller communities. Objectives: To evaluate the association between maximum daily heat index (HI) and morbidity and mortality in 15 New England communities (combined population: 2.7 million) in order to provide actionable evidence for local officials. Methods: We applied overdispersed Poisson nonlinear distributed lag models to evaluate the association between HI and daily (May‐September) emergency department (ED) admissions and deaths in each of 15 study sites in New Hampshire, Maine, and Rhode Island, controlling for time trends, day of week, and federal holidays. Site‐specific estimates were meta‐analyzed to provide regional estimates. Results: Associations (sometimes non‐linear) were observed between HI and each health outcome. For example, a day with a HI of 95°F vs. 75°F was associated with a cumulative 7.5% (95% confidence interval [CI]: 6.5%, 8.5%) and 5.1% (95% CI: 0.2%, 10.3%) higher rate of all‐cause ED visits and deaths, respectively, with some evidence of regional heterogeneity. We estimate that in the study area, days with a HI≥95°F were associated with an annual average of 784 (95% CI: 658, 908) excess ED visits and 22 (95% CI: 3, 39) excess deaths. Conclusions: Our results suggest the presence of adverse health impacts associated with HI below the current local guideline criteria of HI≥100°F used to issue heat advisories. We hypothesize that lowering this threshold may lead to substantially reduced heat‐related morbidity and mortality in the study area. HighlightsHeat‐related morbidity and mortality is a recognized public health concern.The local evidence needed to inform policy is often lacking for smaller communities.We found health impacts at heat index values below the current local guideline criteria used to issue heat advisories.Lowering the guideline criteria may lead to substantially fewer deaths and emergency department visits in New England.

Chapter 7.5 Air quality characterization for environmental public health tracking

Abstract The U.S. Centers for Disease Control and Prevention (CDC) has been given the mandate to develop a national environmental public health tracking network (Tracking Network). The Tracking Network will require both environmental and public health data to be routinely available at a national scale. Historically, the only source of air quality data in the United States that was available on an ongoing and systematic basis at national levels was generated by ambient air monitoring networks put in place for the U.S. Environmental Protection Agencys (EPA) Air Quality Programs. However, new analysis techniques are being developed to use air quality modeling forecasts and satellite data to provide additional information to characterize air quality on a routine basis. With the publics expanding interest in the serious health effects associated with ozone and fine particles, public health officials are looking for ways to better use the available air quality data for use in the Tracking Network. The EPA and the CDC have conducted a collaborative effort entitled the Public Health Air Surveillance Evaluation (PHASE) to evaluate various air quality data sets, from routinely available sources, for specific use by public health officials. The U.S. EPA generated air quality data sets using ambient monitoring data, modeling results, and statistically combined monitoring and modeling data. The EPA, in collaboration with the National Aeronautics and Space Administration (NASA), is also exploring the integration of satellite data with monitoring and modeling data sets to improve available air quality information. The resulting air quality estimates were provided to the CDCs Tracking Network State partners to evaluate the use of these air quality data sets in tracking potential associations between air quality and public health impacts (asthma and cardiovascular disease).