Determinants of per- and polyfluoroalkyl substances (PFAS) exposure among Wisconsin residents.

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) include thousands of manufactured compounds with growing public health concerns due to their potential for widespread human exposure and adverse health outcomes. While PFAS contamination remains a significant concern, especially from ingestion of contaminated food and water, determinants of the variability in PFAS exposure among regional and statewide populations in the United States remains unclear. OBJECTIVES: The objective of this study was to leverage The Survey of the Health of Wisconsin (SHOW), the only statewide representative cohort in the US, to assess and characterize the variability of PFAS exposure in a general population. METHODS: This study sample included a sub-sample of 605 adult participants from the 2014-2016 tri-annual statewide representative sample. Geometric means for PFOS, PFOA, PFNA, PFHxS, PFPeS, PFHpA, and a summed measure of 38 analyzed serum PFAS were presented by demographic, diet, behavioral, and residential characteristics. Multivariate linear regression was used to determine significant predictors of serum PFAS after adjustment. RESULTS: Overall, higher serum concentrations of long-chain PFAS were observed compared with short-chain PFAS. Older adults, males, and non-Hispanic White individuals had higher serum PFAS compared to younger adults, females, and non-White individuals. Eating caught fish in the past year was associated with elevated levels of several PFAS. DISCUSSION: This is among the first studies to characterize serum PFAS among a representative statewide sample in Wisconsin. Both short- and long-chain serum PFAS were detectable for six prominent PFAS. Age and consumption of great lakes fish were the most significant predictors of serum PFAS. State-level PFAS biomonitoring is important for identifying high risk populations and informing state public health standards and interventions, especially among those not living near known contamination sites.

Biomonitoring of perfluoroalkyl and polyfluoroalkyl substances (PFAS) from the Survey of the Health of Wisconsin (SHOW) 2014-2016 and comparison with the National Health and Nutrition Examination Survey (NHANES).

BACKGROUND: Per- and polyfluoroalkyl substances (PFAS) are a growing class of manufactured chemical compounds found in a variety of consumer products. PFAS are ubiquitous in the environment and were found in many humans sampled in the United States (U.S.). Yet, significant gaps in understanding statewide levels of exposure to PFAS remain. OBJECTIVE: The goals of this study are to establish a baseline of exposure at the state level by measuring PFAS serum levels among a representative sample of Wisconsin residents and compare to United States National Health and Nutrition Examination Survey (NHANES). METHODS: The study sample included 605 adults (18+ years of age) selected from the 2014-2016 sample of the Survey of the Health of Wisconsin (SHOW). Thirty-eight PFAS serum concentrations were measured using high-pressure liquid chromatography coupled with tandem mass spectrometric detection (HPLC-MS/MS) and geometric means were presented. Weighted geometric mean serum values of eight PFAS analytes from SHOW were compared to U.S. national levels from the NHANES 2015-2016 sample (PFOS, PFOA, PFNA, PFHxS, PFHpS, PFDA, PFUnDA), and the 2017-2018 sample for Me-PFOSA, PFHPS using the Wilcoxon rank-sum test. RESULTS: PFOS, PFHxS, PFHpS, PFDA, PFNA, and PFOA were detected in over 96% of SHOW participants. In general, SHOW participants had lower serum levels across all PFAS when compared to NHANES. Serum levels increased with age and were higher among males and whites. Similar trends were seen in NHANES, except non-whites had higher PFAS levels at higher percentiles in NHANES. IMPACT STATEMENT: The present study conducts biomonitoring of 38 PFAS among representative sample of residents in the state of Wisconsin. Results suggest that while the majority of Wisconsin residents tested have detectable levels of PFAS in their blood serum, they may have a lower body burden of some PFAS compared to a nationally representative sample. Older adults, males, and whites may have a higher body burden of PFAS relative to other groups, both in Wisconsin and the wider United States.

Description of Kratom Exposure Events in Wisconsin as Reported to the Wisconsin Poison Center, January 1, 2010 to September 1, 2022.

BACKGROUND: Consumption of kratom (Mitragyna speciosa), an herbal substance, can result in adverse health effects. We characterized kratom-associated adverse events in Wisconsin to provide pertinent recommendations for clinicians and public health practitioners. METHODS: Using Wisconsin Poison Center data, we searched for and summarized all records associated with exposure to "kratom," "electronic delivery device containing kratom," or "mitragyna" from January 1, 2010, to September 1, 2022. RESULTS: Kratom-associated exposure calls to the Wisconsin Poison Center increased 3.75 times during 2016 - 2020. Among all 59 calls, 26 (44.1%) reported concomitant use of another substance, agitation was the most common symptom reported (n = 23, 39%), and 7 persons required critical care. Three unintentional ingestions were reported in children aged less than 2 years old. DISCUSSION: Kratom-associated exposure calls to the Wisconsin Poison Center generally have been increasing in frequency since 2011. Wisconsinites who choose to use kratom might benefit from education regarding health risks and safe storage practices to avoid unintentional pediatric exposure.

Silicosis: Emerging Trends and How to Screen for Early Detection.

BACKGROUND: National investigations are finding silicosis in young workers. We developed a silicosis case-finding process and conducted follow-up interviews to identify emerging exposure sources. METHODS: Probable cases were identified through Wisconsin hospital discharge and emergency department data and Wisconsin lung transplant programs. Interviews were attempted with case-patients under age 60. RESULTS: We identified 68 probable silicosis cases and interviewed 4 case-patients. Occupational exposures for cases under age 60 included sandblasting, quarry work, foundry work, coal mining, and stone fabrication. Two stone fabrication workers were diagnosed before age 40. DISCUSSION: Prevention is critically important to eliminate occupational silicosis. Clinicians should obtain the occupational and exposure history to identify cases of occupational lung disease and notify public health to identify and prevent workplace exposures.

Biomonitoring of perfluoroalkyl and polyfluoroalkyl substances (PFAS) from the Survey of the Health of Wisconsin (SHOW) 2014-2016 and comparison with the National Health and Nutrition Examination Survey (NHANES).

Background: Per- and polyfluoroalkyl substances (PFAS) are a growing class of manufactured chemical compounds found in a variety of consumer products. PFAS have become ubiquitous in the environment and were found in many humans sampled in the United States (U.S.). Yet, significant gaps in understanding statewide level exposures to PFAS remain. Objective: The goals of this study are to establish a baseline of exposure at the state level by measuring PFAS serum levels among a representative sample of Wisconsin residents and compare to United States National Health and Nutrition Examination Survey (NHANES). Methods: The study sample included 605 adults (18+ years of age) selected from the 2014-2016 sample of the Survey of the Health of Wisconsin (SHOW). Thirty-eight PFAS serum concentrations were measured using high-pressure liquid chromatography coupled with tandem mass spectrometric detection (HPLC-MS/MS) and geometric means presented. Weighted geometric mean serum values of eight PFAS analytes from SHOW were compared to U.S. national levels from the NHANES 2015-2016 sample (PFOS, PFOA, PFNA, PFHxS, PFHpS, PFDA, PFUnDA), and the 2017-2018 sample for Me-PFOSA, PFHPS using the Wilcoxon rank-sum test. Results: Over 96% of SHOW participants had positive results for PFOS, PFHxS, PFHpS, PFDA, PFNA, and PFOA. In general, SHOW participants had lower serum levels across all PFAS when compared to NHANES. Serum levels increased with age and were higher among males and whites. These trends were seen in NHANES, except non-whites had higher PFAS levels at higher percentiles. Significance: Wisconsin residents may have a lower overall body burden of some PFAS compounds compared to those seen by a nationally representative sample. Additional testing and characterization may be needed in Wisconsin, particularly among non-whites and low socioeconomic status, for which the SHOW sample had less representation compared to NHANES. Impact Statement: The present study conducts biomonitoring of 38 PFAS in the state of Wisconsin and suggests that while most residents of Wisconsin have detectable levels of PFAS in their blood serum, they may have a lower body burden of some PFAS compared to a nationally representative sample. Older adults, males, and whites may have a higher body burden of PFAS relative to other groups both in Wisconsin and the wider United States.

Fish Consumption and Advisory Awareness among a Representative Sample of Wisconsin Adults, 2017-2019.

PURPOSE: To examine fish consumption patterns and fish advisory awareness among Wisconsin adults. DESIGN: Cross-sectional data from population-based survey. Setting: 2017-2019 Wisconsin Behavioral Risk Factor Surveillance System (BRFSS), supplemental fish module. SUBJECTS: 15,757 Wisconsinites aged ≥18 years. Annual response rates ranged 46.1-53.3%. MEASURES: Fish consumption, advisory awareness, background and demographic characteristics. ANALYSIS: Weighted binary and multinomial logistic regression. RESULTS: Most Wisconsinites reported eating fish in the past 30 days, with approximately half (49.8%) consuming less than one fish meal per week. One-fifth of adults reported consuming sportfish. Women were less likely to eat any fish (PORadj = .6, 95% CI: .5-.7) and sportfish than men (PORadj = .7, 95% CI: .6-.8). The majority (76.7%) of sportfish consumers were aware of fish advisories. However, women (PORadj = .7, 95% CI: .5-.9) and black, Indigenous, and people of color (BIPOC) (PORadj = .4, 95% CI: .2-.7) sportfish consumers were less likely to be aware of fish advisories. Compared to adults aged 18-34 years, adults ≥55 years were twice as likely to eat 1-2 fish meals (vs. less than 1 fish meal) per week (PORadj = 2.3, 95% CI: 1.8-2.9). CONCLUSION: Findings indicate that half of all Wisconsinites consumed less fish than recommended by Wisconsin fish advisories, and women and BIPOC respondents were less likely to be aware of advisories. Educational efforts are needed to improve fish consumption habits.

Measuring Work-related Risk of Coronavirus Disease 2019 (COVID-19): Comparison of COVID-19 Incidence by Occupation and Industry-Wisconsin, September 2020 to May 2021.

BACKGROUND: Work-related exposures play an important role in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, yet few studies have compared SARS-CoV-2 expsoure risk across occupations and industries. METHODS: During September 2020 to May 2021, the Wisconsin Department of Health Services collected occupation and industry data as part of routine coronavirus disease 2019 (COVID-19) case investigations. Adults aged 18-64 years with confirmed or probable COVID-19 in Wisconsin were assigned standardized occupation and industry codes. Cumulative incidence rates were weighted for non-response and calculated using full-time equivalent (FTE) workforce denominators from the 2020 American Community Survey. RESULTS: An estimated 11.6% of workers (347 013 of 2.98 million) in Wisconsin, ages 18-64 years, had COVID-19 from September 2020 to May 2021. The highest incidence by occupation (per 100 FTE) occurred among personal care and services workers (22.1), healthcare practitioners and support staff (20.7), and protective services workers (20.7). High-risk sub-groups included nursing assistants and personal care aides (28.8), childcare workers (25.8), food and beverage service workers (25.3), personal appearance workers (24.4), and law enforcement workers (24.1). By industry, incidence was highest in healthcare (18.6); the highest risk sub-sectors were nursing care facilities (30.5) and warehousing (28.5). CONCLUSIONS: This analysis represents one of the most complete examinations to date of COVID-19 incidence by occupation and industry. Our approach demonstrates the value of standardized occupational data collection by public health and may be a model for improved occupational surveillance elsewhere. Workers at higher risk of SARS-CoV-2 exposure may benefit from targeted workplace COVID-19 vaccination and mitigation efforts.

Impact of Epidemic Intelligence Service Training in Occupational Respiratory Epidemiology.

The Centers for Disease Control and Prevention's Epidemic Intelligence Service (EIS) is a fellowship in applied epidemiology for physicians, veterinarians, nurses, scientists, and other health professionals. Each EIS fellow is assigned to a position at a federal, state, or local site for 2 years of on-the-job training in outbreak investigation, epidemiologic research, surveillance system evaluation, and scientific communication. Although the original focus of the program on the control of infectious diseases remains salient, positions are available for training in other areas of public health, including occupational respiratory disease. In this Perspective, we describe the EIS program, highlight three positions (one federal and two state-based) that provide training in occupational respiratory epidemiology, and summarize trainees' experiences in these positions over a 30-year period. For early-career health professionals interested in understanding and preventing occupational respiratory hazards and diseases, EIS offers a unique career development opportunity.

Incidence of COVID-19 and Worker's Compensation Utilization Among Food Manufacturing in Wisconsin, October 1, 2020 - December 31, 2021.

BACKGROUND: The food manufacturing industry is a critical economic sector and has been a high-risk industry for COVID-19. This analysis aimed to describe COVID-19 cumulative case incidence rates among Wisconsin food manufacturing workers and their worker's compensation utilization. METHODS: This was a descriptive analysis of COVID-19 cases among food manufacturing industry workers in Wisconsin from October 1, 2020, through December 31, 2021. RESULTS: Occupations with the highest cumulative case incidence rate (per 1000 workers) were Packers and Packagers, Hand (275; 95% CI, 252-300), Packaging and Filling Machine Operators and Tenders (266; 95% CI, 254-277), and Laborers and Freight, Stock and Material Movers, Hand (261; 95% CI, 247-276). Two worker's compensation claims were paid to food manufacturing workers. DISCUSSION: Wisconsin food manufacturing workers were disproportionately affected by COVID-19, with a high cumulative case incidence rate exceeding that of the manufacturing industry overall, statewide non-institutionalized working-age adults, and the ambulatory health care industry. There was also a disproportionately low use of worker's compensation benefits in Wisconsin compared to the high COVID-19 disease incidence. Improved worker protections for occupational infectious diseases with high risk of transmission are needed as well as improvements to the worker's compensation system.

School District Prevention Policies and Risk of COVID-19 Among In-Person K-12 Educators, Wisconsin, 2021.

Objectives. To assess the rate of COVID-19 among in-person K-12 educators and the rate's association with various COVID-19 prevention policies in school districts. Methods. We linked actively working, in-person K-12 educators in Wisconsin to COVID-19 cases with onset from September 2 to November 24, 2021. A mixed-effects Cox proportional hazards model, adjusted for pertinent person- and community-level confounders, compared the hazard rate of COVID-19 among educators working in districts with and without specific COVID-19 prevention policies. Results. In-person educators working in school districts that required masking for students and staff experienced 19% lower hazards of COVID-19 than did those in districts without any masking policy (hazard ratio = 0.81; 95% confidence interval = 0.72, 0.92). Reduced COVID-19 hazards were consistent and remained statistically significant when educators were stratified by elementary, middle, and high school environments. Conclusions. In Wisconsin's K-12 school districts, during the fall 2021 academic semester, a policy that required both students and staff to mask was associated with significantly reduced risk of COVID-19 among in-person educators across all grade levels. (Am J Public Health. 2022;112(12):1791-1799. https://doi.org/10.2105/AJPH.2022.307095).

Lost time: COVID-19 indemnity claim reporting and results in the Wisconsin workers' compensation system from March 12 to December 31, 2020.

BACKGROUND: The COVID-19 pandemic introduced a new compensable infectious disease to workplaces. METHODS: This was a descriptive analysis of Wisconsin COVID workers' compensation (WC) claims between March 12 and December 31, 2020. The impact of the presumption law (March 12 to June 10, 2020) was also evaluated. RESULTS: Less than 1% of working-age residents with COVID-19 filed a claim. COVID-19 WC claim rates (per 100,000 FTE) were notably low for frontline industry sectors such as Retail Trade (n = 115), Manufacturing (n = 88), and Wholesale Trade (n = 31). Healthcare workers (764 claims per 100,000 FTE) comprised 73.2% of COVID-19 claims. Most claims (52.8%) were denied and the proportion of denied claims increased significantly after the presumption period for both first responders and other occupations. CONCLUSION: The presumption law made benefits accessible primarily to first responders. Further changes to WC systems are needed to offset the individual and collective costs of infectious diseases.

Fish consumption and advisory awareness in the Great Lakes basin.

BACKGROUND: Fish is a dietary staple in the United States. Risk of exposure to persistent contaminants through fish consumption is a significant health concern. Great Lakes basin states, along with the US Environmental Protection Agency and the Great Lakes Consortium for Fish Consumption Advisories, have developed and continuously updated fish consumption advisories specifically for the Great Lakes basin residents. OBJECTIVES: To characterize Great Lakes basin residents' fish consumption and advisory awareness, we conducted a point-in-time survey to describe fish consumption habits and awareness of state and EPA/FDA fish advisories. METHODS: We used a randomized, address-based sampling approach to recruit respondents from the eight Great Lakes basin states. Weighted survey analysis procedures were used to estimate population prevalence of fish consumption habits, state and EPA/FDA advisory awareness, and demographic and background characteristics. Logistic regression models were used to assess the associations between demographic and background factors and fish consumption and awareness of advisories, respectively. RESULTS: About 92% of respondents, representing an estimated 61 million adults, reported eating fish in the last 12 months. About 64% of respondents only consumed commercial fish, and an estimated 5 million fish consumers exceeded the EPA/FDA recommended limit for fish meals. Minorities were more likely to exceed the EPA/FDA recommended limit. About half of the respondents were aware of state or EPA/FDA advisories; however, minorities and women were less aware of the EPA/FDA advisory. After adjusting for demographic characteristics, sportfish consumption was significantly associated with state advisory awareness; commercial fish consumption was significantly associated with EPA/FDA awareness. DISCUSSION: Most respondents only consumed commercial fish, but an estimated 18.6 million adults consumed sportfish. While half of the fish consumers were aware of state or EPA/FDA advisories, minorities and women continue to be less aware of fish advisories. Improved outreach strategies are needed to inform them about safe fish-consumption guidelines.

SARS-CoV-2 Wastewater Surveillance for Public Health Action.

Wastewater surveillance for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has garnered extensive public attention during the coronavirus disease pandemic as a proposed complement to existing disease surveillance systems. Over the past year, methods for detection and quantification of SARS-CoV-2 viral RNA in untreated sewage have advanced, and concentrations in wastewater have been shown to correlate with trends in reported cases. Despite the promise of wastewater surveillance, for these measurements to translate into useful public health tools, bridging the communication and knowledge gaps between researchers and public health responders is needed. We describe the key uses, barriers, and applicability of SARS-CoV-2 wastewater surveillance for supporting public health decisions and actions, including establishing ethics consideration for monitoring. Although wastewater surveillance to assess community infections is not a new idea, the coronavirus disease pandemic might be the initiating event to make this emerging public health tool a sustainable nationwide surveillance system, provided that these barriers are addressed.

Severe Acute Respiratory Syndrome Coronavirus 2 Transmission in Intercollegiate Athletics Not Fully Mitigated With Daily Antigen Testing.

BACKGROUND: High-frequency, rapid-turnaround severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing continues to be proposed as a way of efficiently identifying and mitigating transmission in congregate settings. However, 2 SARS-CoV-2 outbreaks occurred among intercollegiate university athletic programs during the fall 2020 semester, despite mandatory directly observed daily antigen testing. METHODS: During the fall 2020 semester, athletes and staff in both programs were tested daily using Quidel's Sofia SARS Antigen Fluorescent Immunoassay, with positive antigen results requiring confirmatory testing with real-time reverse-transcription polymerase chain reaction. We used genomic sequencing to investigate transmission dynamics in these 2 outbreaks. RESULTS: In the first outbreak, 32 confirmed cases occurred within a university athletics program after the index patient attended a meeting while infectious, despite a negative antigen test on the day of the meeting. Among isolates sequenced from that outbreak, 24 (92%) of 26 were closely related, suggesting sustained transmission following an initial introduction event. In the second outbreak, 12 confirmed cases occurred among athletes from 2 university programs that faced each other in an athletic competition, despite receipt of negative antigen test results on the day of the competition. Sequences from both teams were closely related and distinct from viruses circulating in the community for team 1, suggesting transmission during intercollegiate competition in the community for team 2. CONCLUSIONS: These findings suggest that antigen testing alone, even when mandated and directly observed, may not be sufficient as an intervention to prevent SARS-CoV-2 outbreaks in congregate settings, and they highlight the importance of vaccination to prevent SARS-CoV-2 outbreak in congregate settings.

SARS-CoV-2 transmission in intercollegiate athletics not fully mitigated with daily antigen testing.

BACKGROUND: High frequency, rapid turnaround SARS-CoV-2 testing continues to be proposed as a way of efficiently identifying and mitigating transmission in congregate settings. However, two SARS-CoV-2 outbreaks occurred among intercollegiate university athletic programs during the fall 2020 semester despite mandatory directly observed daily antigen testing. METHODS: During the fall 2020 semester, athletes and staff in both programs were tested daily using Quidel's Sofia SARS Antigen Fluorescent Immunoassay (FIA), with positive antigen results requiring confirmatory testing with real-time reverse transcription polymerase chain reaction (RT-PCR). We used genomic sequencing to investigate transmission dynamics in these two outbreaks. RESULTS: In Outbreak 1, 32 confirmed cases occurred within a university athletics program after the index patient attended a meeting while infectious despite a negative antigen test on the day of the meeting. Among isolates sequenced from Outbreak 1, 24 (92%) of 26 were closely related, suggesting sustained transmission following an initial introduction event. In Outbreak 2, 12 confirmed cases occurred among athletes from two university programs that faced each other in an athletic competition despite receiving negative antigen test results on the day of the competition. Sequences from both teams were closely related and unique from strains circulating in the community, suggesting transmission during intercollegiate competition. CONCLUSIONS: These findings suggest that antigen testing alone, even when mandated and directly observed, may not be sufficient as an intervention to prevent SARS-CoV-2 outbreaks in congregate settings, and highlights the importance of supplementing serial antigen testing with appropriate mitigation strategies to prevent SARS-CoV-2 outbreak in congregate settings. SUMMARY: High frequency, rapid turnaround SARS-CoV-2 testing continues to be proposed as a way of efficiently identifying and mitigating transmission in congregate settings. However, here we describe two SARS-CoV-2 outbreaks occurred among intercollegiate university athletic programs during the fall 2020 semester.

Fish consumption and awareness of fish advisories among Burmese refugees: A respondent-driven sampling study in Milwaukee, Wisconsin.

BACKGROUND: Since 2000, more than 6000 Burmese refugees were resettled in Wisconsin. The Burmese diet is traditionally rich in fish and fish products, and studies show that Burmese refugees continue to rely on local waterbodies for food. Given that Wisconsin has five Areas of Concern (AOC) that are severely affected by pollution, long-term exposure to contaminants in sport-caught fish is a health concern. To better understand fish consumption among Burmese refugees, we conducted a biomonitoring study in Milwaukee. The present study examined Burmese refugees' fish consumption habits and awareness of fish advisories. METHODS: We used respondent-driven sampling (RDS) methodology to recruit Burmese refugees in Milwaukee. RDS Analysis Tool 7.1 was used to obtain adjusted population estimates for demographic characteristics, fish consumption habits, and awareness of fish advisories. Homophily and equilibrium were investigated to evaluate the effectiveness of RDS in recruitment. RESULTS: Initiated by five active seeds, we recruited 103 respondents to participate in the study. Respondents had a strong preference to recruit those with the same ethnicity (Homophily-score: 0.614 to 0.699) and a relatively weak preference to recruit those with the same sex (Homophily-score: 0.188 to 0.222) to participate in our study. The majority (72.5%) of respondents were women of childbearing age (WCBA). Most (68.5%) had 8th grade or less education. Regarding sportfish consumption per month in the last year, 30.6% reported eating 1-3 meals and 21.2% reported eating more than 3 meals. When asked about purchased fish consumption per month, 26.3% reported eating 1-3 meals. The overwhelming majority were not aware of safe-eating sportfish guidelines for Wisconsin (88.3%) or Milwaukee waterbodies (96.6%). CONCLUSIONS: RDS is an effective methodology to recruit hard-to-reach populations, such as the Burmese surveyed in this study. High percentages of WCBA eating potentially contaminated sportfish meals, low awareness of consumption advisories, and limited economic resources make the Burmese population more likely to be exposed to contaminants. Health education efforts should be focused in this vulnerable population, particularly among Burmese WCBA.

Trends in Outbreak-Associated Cases of COVID-19 - Wisconsin, March-November 2020.

During September 3-November 16, 2020, daily confirmed cases of coronavirus disease 2019 (COVID-19) reported to the Wisconsin Department of Health Services (WDHS) increased at a rate of 24% per week, from a 7-day average of 674 (August 28-September 3) to 6,426 (November 10-16) (1). The growth rate during this interval was the highest to date in Wisconsin and among the highest in the United States during that time (1). To characterize potential sources of this increase, the investigation examined reported outbreaks in Wisconsin that occurred during March 4-November 16, 2020, with respect to their setting and number of associated COVID-19 cases.

The Biomonitoring of Great Lakes Populations-III Program: The Milwaukee Angler Project.

As part of our continued effort to highlight innovative approaches to improve the health and environment of communities, the Journal is pleased to publish regular columns from the Agency for Toxic Substances and Disease Registry (ATSDR) at the Centers for Disease Control and Prevention (CDC). ATSDR serves the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and diseases related to toxic substances. The purpose of this column is to inform readers of ATSDR's activities and initiatives to better understand the relationship between exposure to hazardous substances in the environment, its impact on human health, and how to protect public health. The conclusions of this column are those of the author(s) and do not necessarily represent the official position of ATSDR or CDC.