Building the Future of Environmental Public Health Tracking: Proceedings and Recommendations of an Expert Panel Workshop.

Since 2002, the national Environmental Health Tracking Program of the Centers for Disease Control and Prevention (CDC) has provided vital support to state environmental public health efforts while simultaneously building a nationwide network of state, local, and academic partners to improve our nation's capacity to understand and respond to environmental threats to public health. As part of program review and strategic planning, national thought leaders in environmental public health were convened to assess progress, identify gaps and challenges, and provide recommendations for enhancing the utility and impact of the Tracking Program. Several opportunities were identified. Chief among these was the need for continued and expanded CDC leadership to develop a coordinated Tracking Program agenda identifying specific scientific goals, data needs, and initiatives. Recommendations for future growth included expanded data availability and program coverage: i.e., making data available at the community scale and establishing tracking programs in all 50 states. Finally, a set of recommendations emphasizing communication to decision makers and the public was made that will be integral to the future utility and success of the Tracking Program.

Myocardial Late Gadolinium Enhancement: Accuracy of T1 Mapping-based Synthetic Inversion-Recovery Imaging.

PURPOSE: To compare the accuracy of detection and quantification of myocardial late gadolinium enhancement (LGE) with a synthetic inversion-recovery (IR) approach with that of conventional IR techniques. MATERIALS AND METHODS: This prospective study was approved by the institutional review board and compliant with HIPAA. All patients gave written informed consent. Between June and November 2014, 43 patients (25 men; mean age, 54 years ± 16) suspected of having previous myocardial infarction underwent magnetic resonance (MR) imaging, including contrast material-enhanced LGE imaging and T1 mapping. Synthetic magnitude and phase-sensitive IR images were generated on the basis of T1 maps. Images were assessed by two readers. Differences in the per-patient and per-segment LGE detection rates between the synthetic and conventional techniques were analyzed with the McNemar test, and the accuracy of LGE quantification was calculated with the paired t test and Bland-Altman statistics. Interreader agreement for the detection and quantification of LGE was analyzed with κ and Bland-Altman statistics, respectively. RESULTS: Seventeen of the 43 patients (39%) had LGE patterns consistent with myocardial infarction. The sensitivity and specificity of synthetic magnitude and phase-sensitive IR techniques in the detection of LGE were 90% and 95%, respectively, with patient-based analysis and 94% and 99%, respectively, with segment-based analysis. The area of LGE measured with synthetic IR techniques showed excellent agreement with that of conventional techniques (4.35 cm(2) ± 1.88 and 4.14 cm(2)± 1.62 for synthetic magnitude and phase-sensitive IR, respectively, compared with 4.25 cm(2) ± 1.92 and 4.22 cm(2) ± 1.86 for conventional magnitude and phase-sensitive IR, respectively; P > .05). Interreader agreement was excellent for the detection (κ > 0.81) and quantification (bias range, -0.34 to 0.40; P > .05) of LGE. CONCLUSION: The accuracy of the T1 map-based synthetic IR approach in the detection and quantification of myocardial LGE in patients with previous myocardial infarction was similar to that of conventional IR techniques. The use of T1 mapping to derive synthetic LGE images may reduce imaging times and operator dependence in future T1 mapping protocols with full left ventricular coverage.

Clinical feasibility of a myocardial signal intensity threshold-based semi-automated cardiac magnetic resonance segmentation method.

OBJECTIVES: To assess the accuracy and efficiency of a threshold-based, semi-automated cardiac MRI segmentation algorithm in comparison with conventional contour-based segmentation and aortic flow measurements. METHODS: Short-axis cine images of 148 patients (55 ± 18 years, 81 men) were used to evaluate left ventricular (LV) volumes and mass (LVM) using conventional and threshold-based segmentations. Phase-contrast images were used to independently measure stroke volume (SV). LV parameters were evaluated by two independent readers. RESULTS: Evaluation times using the conventional and threshold-based methods were 8.4 ± 1.9 and 4.2 ± 1.3 min, respectively (P < 0.0001). LV parameters measured by the conventional and threshold-based methods, respectively, were end-diastolic volume (EDV) 146 ± 59 and 134 ± 53 ml; end-systolic volume (ESV) 64 ± 47 and 59 ± 46 ml; SV 82 ± 29 and 74 ± 28 ml (flow-based 74 ± 30 ml); ejection fraction (EF) 59 ± 16 and 58 ± 17%; and LVM 141 ± 55 and 159 ± 58 g. Significant differences between the conventional and threshold-based methods were observed in EDV, ESV, and LVM mesurements; SV from threshold-based and flow-based measurements were in agreement (P > 0.05) but were significantly different from conventional analysis (P < 0.05). Excellent inter-observer agreement was observed. CONCLUSIONS: Threshold-based LV segmentation provides improved accuracy and faster assessment compared to conventional contour-based methods. KEY POINTS: • Threshold-based left ventricular segmentation provides time-efficient assessment of left ventricular parameters • The threshold-based method can discriminate between blood and papillary muscles • This method provides improved accuracy compared to aortic flow measurements as a reference.

Multidetector computed tomography pulmonary angiography in childhood acute pulmonary embolism.

Pulmonary embolism is a life-threatening condition affecting people of all ages. Multidetector row CT pulmonary angiography has improved the imaging of pulmonary embolism in both adults and children and is now regarded as the routine modality for detection of pulmonary embolism. Advanced CT pulmonary angiography techniques developed in recent years, such as dual-energy CT, have been applied as a one-stop modality for pulmonary embolism diagnosis in children, as they can simultaneously provide anatomical and functional information. We discuss CT pulmonary angiography techniques, common and uncommon findings of pulmonary embolism in both conventional and dual-energy CT pulmonary angiography, and radiation dose considerations.

Global methylmercury exposure from seafood consumption and risk of developmental neurotoxicity: a systematic review.

OBJECTIVE: To examine biomarkers of methylmercury (MeHg) intake in women and infants from seafood-consuming populations globally and characterize the comparative risk of fetal developmental neurotoxicity. METHODS: A search was conducted of the published literature reporting total mercury (Hg) in hair and blood in women and infants. These biomarkers are validated proxy measures of MeHg, a neurotoxin found primarily in seafood. Average and high-end biomarkers were extracted, stratified by seafood consumption context, and pooled by category. Medians for average and high-end pooled distributions were compared with the reference level established by a joint expert committee of the Food and Agriculture Organization (FAO) and the World Health Organization (WHO). FINDINGS: Selection criteria were met by 164 studies of women and infants from 43 countries. Pooled average biomarkers suggest an intake of MeHg several times over the FAO/WHO reference in fish-consuming riparians living near small-scale gold mining and well over the reference in consumers of marine mammals in Arctic regions. In coastal regions of south-eastern Asia, the western Pacific and the Mediterranean, average biomarkers approach the reference. Although the two former groups have a higher risk of neurotoxicity than the latter, coastal regions are home to the largest number at risk. High-end biomarkers across all categories indicate MeHg intake is in excess of the reference value. CONCLUSION: There is a need for policies to reduce Hg exposure among women and infants and for surveillance in high-risk populations, the majority of which live in low-and middle-income countries.

Project update: evaluating the community health legacy of WWI chemical weapons testing.

The Spring Valley community of Washington, District of Columbia, was built on the site of a World War I chemical weapons lab where testing activities had distributed arsenic to surface soil and waste disposal had resulted in localized subsurface contamination. In previous work, findings were suggestive of potential site-related health issues, although no evidence of cancer clustering was found. In follow-up, we updated the community health assessment and explored time trends for several arsenic-related cancers. Health indicators continue to be very good in Spring Valley. For all major causes of mortality, Spring Valley rates were lower than United States (US) rates with most substantially lower (20-80 %); rates for heart diseases, Alzheimer's, and essential hypertension and related kidney disease were only slightly lower than US rates (3-8 %). Incidence and mortality rates for the selected cancers in the Spring Valley area were lower than US rates. Small non-statistically significant increasing time trends were observed in Spring Valley for incidence of two arsenic-related cancers: bladder and lung and bronchus. A moderate statistically significant increasing rate trend was observed for lung and bronchus cancer mortality in Spring Valley (p < 0.01). Lung and bronchus cancer mortality rates were also increasing in the Chevy Chase community, the local comparison area closely matched to Spring Valley on important demographic variables, suggesting that the observed increases may not be site-related. A full profile of common cancer site rates and trends for both study areas was suggested to better understand the rate trend findings but no epidemiological study was recommended.

State public health laboratory biomonitoring programs: implementation and early accomplishments.

In 2009, the Centers for Disease Control and Prevention funded three state-based public health laboratory biomonitoring programs. These programs are the foundation for a National Biomonitoring Plan that consists of a larger network of state and local biomonitoring programs. To understand the utility of these programs and plan for the larger network, interviews were conducted with the program officials. The goal was to gather information on the challenges, successes, and lessons learned in program launch and implementation. Representatives of all programs participated. Projects range from statewide efforts to focused community investigations. Each program focuses on specific analytes including metals, pesticides, and other organics. Main accomplishments reported include development of laboratory and field capacity as well as generation of analytical results. Common challenges reported were laboratory setup and operation, sample collection and logistics, and staff recruitment. Respondents made specific recommendations for improving effectiveness of the current programs as well as ways to advance the National Biomonitoring Plan.

Association of markers of chronic viral hepatitis and blood mercury levels in US reproductive-age women from NHANES 2001-2008: a cross-sectional study.

BACKGROUND: Methylmercury (MeHg) is a neurotoxin primarily found in seafood; exposures in reproductive-age women are of concern due to vulnerability of the developing fetus. MeHg is mainly eliminated via an enterohepatic cycle involving the liver and gallbladder. Dysfunction in these organs has been associated with slower MeHg elimination in laboratory animals. We hypothesized that women testing positive for chronic hepatitis B (HBV) or C (HCV), both associated with risk of longer-term liver and gallbladder impairment, would have higher total blood mercury (TBHg) concentrations than those negative for the viruses, reflecting slower MeHg elimination. METHODS: Geometric mean (GM) TBHg levels from a representative sample of over 5,000 seafood-consuming, reproductive-age women from eight years (2001-2008) of the US NHANES survey were compared by viral hepatitis status (as determined by serological assay) using multiple linear regression. Adjustment was made for estimated MeHg intake from seafood consumption, social and demographic variables and other predictors. RESULTS: Women with chronic HBV had 1.52 (95% CI 1.13, 2.05, p < 0.01) times the GM TBHg of women who had not come into contact with the virus. The positive association was strongest in those with most severe disease. A modest negative association was found with HCV markers. CONCLUSIONS: While study design prevents inferences on causality, the finding that MeHg biomarkers differ by hepatitis status in this population suggests viral hepatitis may alter the pace of MeHg elimination. Offspring of HBV-infected seafood-consuming women may be at higher risk of MeHg-induced developmental delays than offspring of those uninfected. Possible reasons for the unanticipated negative association with HCV are explored.

Pilot study and cumulative risk framework to advance long-haul driver health.

Commercial drivers are essential to the economic recovery, yet their work exposes them to many health and safety hazards. Research to improve driver health should be designed with an understanding of both the complex occupational environment and the risk management context. We present results from a small pilot study of driver health concerns and behaviors to illustrate concepts and frameworks from human health risk assessment and management that may assist in the design and translation of driver and other worker health research. The pilot study surveyed 18 long-haul truck drivers at a truck stop using an instrument adapted from the International Physical Activity Questionnaire and a transient community needs assessment developed for the US Antarctic Program Recreation and Wellness Survey. Respondents' characteristics and health concerns reflect existing literature: mostly male of older age with musculoskeletal and chronic health conditions. The two most common barriers to physical activity were lack of time and physical limitations. Applying cumulative risk assessment and risk-based decision-making frameworks, we suggest that preventive health management opportunities can be improved for these transient workers through actions of employers, truck stop owners and their communities. Considering lessons learned in implementing the pilot, cumulative risk assessment, and risk-based decision making in research design can facilitate holistic research considering co-exposures, risk factors and mitigators across multiple domains of health to inform worker protection.

Charting a Path Forward: Assessing the Science of Chemical Risk Evaluations under the Toxic Substances Control Act in the Context of Recent National Academies Recommendations.

BACKGROUND: In 2016, Congress enacted the Frank R. Lautenberg Chemical Safety for the 21st Century Act ("the Lautenberg Act"), which made major revisions to the main U.S. chemical safety law, the 1976 Toxic Substances Control Act (TSCA). Among other reforms, the Lautenberg Act mandates that the U.S. Environmental Protection Agency (U.S. EPA) conduct comprehensive risk evaluations of chemicals in commerce. The U.S. EPA recently finalized the first set of such chemical risk evaluations. OBJECTIVES: We examine the first 10 TSCA risk evaluations in relation to risk science recommendations from the National Academies to determine consistency with these recommendations and to identify opportunities to improve future TSCA risk evaluations by further implementing these key approaches and methods. DISCUSSION: Our review of the first set of TSCA risk evaluations identified substantial deviations from best practices in risk assessment, including overly narrow problem formulations and scopes; insufficient characterization of uncertainty in the evidence; inadequate consideration of population variability; lack of consideration of background exposures, combined exposures, and cumulative risk; divergent approaches to dose-response assessment for carcinogens and noncarcinogens; and a flawed approach to systematic review. We believe these deviations result in underestimation of population exposures and health risks. We are hopeful that the agency can use these insights and have provided suggestions to produce chemical risk evaluations aligned with the intent and requirements of the Lautenberg Act and the best available science to better protect health and the environment-including the health of those most vulnerable to chemical exposures. https://doi.org/10.1289/EHP9649.

The impact of local environmental health capacity on foodborne illness morbidity in Maryland.

OBJECTIVES: We evaluated the relationship between local food protection capacity and service provision in Maryland's 24 local food protection programs (FPPs) and incidence of foodborne illness at the county level. METHODS: We conducted regression analyses to determine the relationship between foodborne illness and local FPP characteristics. We used the Centers for Disease Control and Prevention's FoodNet and Maryland Department of Health and Mental Hygiene outbreak data set, along with data on Maryland's local FPP capacity (workforce size and experience levels, budget) and service provision (food service facility inspections, public notification programs). RESULTS: Counties with higher capacity, such as larger workforce, higher budget, and greater employee experience, had fewer foodborne illnesses. Counties with better performance and county-level regulations, such as high food service facility inspection rates and requiring certified food manager programs, respectively, had lower rates of illness. CONCLUSIONS: Counties with strong local food protection capacity and services can protect the public from foodborne illness. Research on public health services can enhance our understanding of the food protection infrastructure, and the effectiveness of food protection programs in preventing foodborne illness.

Cumulative Risks from Stressor Exposures and Personal Risk Factors in the Workplace: Examples from a Scoping Review.

Protecting worker and public health involves an understanding of multiple determinants, including exposures to biological, chemical, or physical agents or stressors in combination with other determinants including type of employment, health status, and individual behaviors. This has been illustrated during the COVID-19 pandemic by increased exposure and health risks for essential workers and those with pre-existing conditions, and mask-wearing behavior. Health risk assessment practices for environmental and occupational health typically do not incorporate multiple stressors in combination with personal risk factors. While conceptual developments in cumulative risk assessment to inform a more holistic approach to these real-life conditions have progressed, gaps remain, and practical methods and applications are rare. This scoping review characterizes existing evidence of combined stressor exposures and personal factors and risk to foster methods for occupational cumulative risk assessment. The review found examples from many workplaces, such as manufacturing, offices, and health care; exposures to chemical, physical, and psychosocial stressors combined with modifiable and unmodifiable determinants of health; and outcomes including respiratory function and disease, cancers, cardio-metabolic diseases, and hearing loss, as well as increased fertility, menstrual dysfunction and worsened mental health. To protect workers, workplace exposures and modifiable and unmodifiable characteristics should be considered in risk assessment and management. Data on combination exposures can improve assessments and risk estimates and inform protective exposure limits and management strategies.

Multi-Criteria Decision Analysis Model for Assessing the Risk from Multi-Ingredient Dietary Supplements (MIDS).

Military personnel use dietary supplements (DS) for performance enhancement, bodybuilding, weight loss, and to maintain health. Adverse events, including cardiovascular (CV) effects, have been reported in military personnel taking supplements. Previous research determined that ingestion of multi-ingredient dietary supplements (MIDS), can lead to signals of safety concerns. Therefore, to assess the safety of MIDS, the Department of Defense via a contractor explored the development of a model-based risk assessment tool. We present a strategy and preliminary novel multi-criteria decision analysis (MCDA)-based tool for assessing the risk of adverse CV effects from MIDS. The tool integrates toxicology and other relevant data available on MIDS; likelihood of exposure, and biologic plausibility that could contribute to specific aspects of risk.Inputs for the model are values of four measures assigned based on the available evidence supplemented with the opinion of experts in toxicology, modeling, risk assessment etc. Measures were weighted based on the experts' assessment of measures' relative importance. Finally, all data for the four measures were integrated to provide a risk potential of 0 (low risk) to 100 (high risk) that defines the relative risk of a MIDS to cause adverse reactions.We conclude that the best available evidence must be supplemented with the opinion of experts in medicine, toxicology and pharmacology. Model-based approaches are useful to inform risk assessment in the absence of data. This MCDA model provides a foundation for refinement and validation of accuracy of the model predictions as new evidence becomes available.

Early Warnings: The Lessons of COVID-19 for Public Health Climate Preparedness.

The early 2020 response to COVID-19 revealed major gaps in public health systems around the world as many were overwhelmed by a quickly-spreading new coronavirus. While the critical task at hand is turning the tide on COVID-19, this pandemic serves as a clarion call to governments and citizens alike to ensure public health systems are better prepared to meet the emergencies of the future, many of which will be climate-related. Learning from the successes as well as the failures of the pandemic response provides some guidance. We apply several recommendations of a recent World Health Organization Policy Brief on COVID-19 response to 5 key areas of public health systems - governance, information, services, determinants, and capacity - to suggest early lessons from the coronavirus pandemic for climate change preparedness. COVID-19 has demonstrated how essential public health is to well-functioning human societies and how high the economic cost of an unprepared health system can be. This pandemic provides valuable early warnings, with lessons for building public health resilience.

COVID-19 stressors on migrant workers in Kuwait: cumulative risk considerations.

As a marginalised subpopulation, migrant workers often fall short from protection by public policies, they take precarious jobs with unsafe working and living conditions and they grapple with cultural and linguistic barriers. In light of the current COVID-19 pandemic, migrant workers are now exposed to additional stressors of the virus and related responses. We applied a comprehensive qualitative cumulative risk assessment framework for migrant workers living in Kuwait. This pandemic could be one of the few examples where the stressors overlap all domains of migrant workers' lives. No single intervention can solve all the problems; there must be a set of interventions to address all domains. Local authorities and employers must act quickly to stop the spread, ensure easy access to testing and treatment, provide adequate housing and clear communication, encourage wide social support, safeguard financial protection and mental well-being and continuously re-evaluate the situation as more data are collected.

Extreme temperatures and mortality in Kuwait: Who is vulnerable?

BACKGROUND: Previous climate change temperature-related health studies have been performed mostly in western countries with relatively cooler temperatures than the Gulf region. Regions that are inherently hot, like Kuwait, are witnessing soaring temperatures unlike ever before. Meanwhile, Kuwait and other Gulf countries are unique in their demographic profiles due to the large number of non-national migrant workers. OBJECTIVE: To examine the associations of hot and cold temperature extremes on the risk of mortality across gender, age groups and nationality in Kuwait. METHODS: We investigated daily variations of all-cause non-accidental and cardiovascular mortality death counts and ambient temperatures from 2010 to 2016 in a time-series design using a negative binomial distribution. The temperature lag was modeled with distributed lag non-linear models. RESULTS: A total of 33,472 all-cause non-accidental deaths happened during the study period. For the extreme hot temperatures and over the entire lag period, comparing the 99th percentile of temperature to the minimum mortality temperature, the risk of dying among males was 2.08 (95% CI: 1.23-3.52). Among non-Kuwaitis, males and working age group (15-64 year) had relative risks of death from extreme hot temperatures of 2.90 (1.42-5.93), and 2.59 (1.20-5.59), respectively. For extreme cold temperatures and over the entire lag period, comparing the 1st percentile of temperature to the minimum mortality temperature, the relative risk of death among Kuwaitis was 2.03 (1.05-3.93). Elderly Kuwaitis (65+ year) exposed to extreme cold temperatures had a relative risk of 2.75 (1.16-6.52). CONCLUSIONS: Certain subpopulations in Kuwait are vulnerable to extreme temperatures with doubling to tripling risk of mortality. Nationality is an important effect modifier in temperature-related mortality studies in Kuwait and possibly the Gulf region. To the best of our knowledge, we are the first study to examine specific subpopulation vulnerabilities to temperature in this region. Our findings could carry a potential for broader insight into similar hyper-arid and hot regions.

The human health risk estimation of inhaled oil spill emissions with and without adding dispersant.

Airborne toxic compounds emitted from polluted seawater polluted after an oil spill raise health concerns when inhaled by humans or other species. Inhalation of these toxic compounds as volatile organic compounds (VOCs) or airborne fine particulate matter (PM) may cause serious pulmonary diseases, including lung cancer. Spraying chemical dispersants to enhance distribution of the crude oil into the water was employed extensively during the Deepwater Horizon spill. There is some evidence that dispersion of the crude oil decreased the emission rate of the VOCs but increased the emission rates of fine PM that may carry toxic compounds. In this study, the cancer risks and non-cancer hazards of the detected VOCs and particulates for spill-response workers were estimated with and without use of dispersant under action of breaking waves. A subchronic exposure scenario was modeled to address the inhalation health threat during initial phases of an oil spill response. A dosimetry model was used to estimate regional deposition of PM. Use of dispersant reduced benzene cancer risks from 57 to 37 excess lifetime cancer cases per million for 1 h of daily exposure that continues for 3 months. Adding dispersant resulted in emissions reductions of the lighter VOCs (up to 30% lower). However, hazard quotients (HQs) of the non-carcinogenic VOCs even after dispersant addition were above 1 meaning there are serious concerns about exposure to these VOCs. Inhalation of airborne particles emitted from the slick containing dispersant increased the total mass of deposited particles in upper respiratory regions compared to the slick of crude oil only. This study showed the application of dispersant onto the pollution slick increased the total mass burden to the human respiratory system about 10 times, an exploratory HQ analysis is presented to evaluate the potential health risk.

Implications of applying cumulative risk assessment to the workplace.

Multiple changes are influencing work, workplaces and workers in the US including shifts in the main types of work and the rise of the 'gig' economy. Work and workplace changes have coincided with a decline in unions and associated advocacy for improved safety and health conditions. Risk assessment has been the primary method to inform occupational and environmental health policy and management for many types of hazards. Although often focused on one hazard at a time, risk assessment frameworks and methods have advanced toward cumulative risk assessment recognizing that exposure to a single chemical or non-chemical stressor rarely occurs in isolation. We explore how applying cumulative risk approaches may change the roles of workers and employers as they pursue improved health and safety and elucidate some of the challenges and opportunities that might arise. Application of cumulative risk assessment should result in better understanding of complex exposures and health risks with the potential to inform more effective controls and improved safety and health risk management overall. Roles and responsibilities of both employers and workers are anticipated to change with potential for a greater burden of responsibility on workers to address risk factors both inside and outside the workplace that affect health at work. A range of policies, guidance and training have helped develop cumulative risk assessment for the environmental health field and similar approaches are available to foster the practice in occupational safety and health.

An Overview of Literature Topics Related to Current Concepts, Methods, Tools, and Applications for Cumulative Risk Assessment (2007-2016).

Cumulative risk assessments (CRAs) address combined risks from exposures to multiple chemical and nonchemical stressors and may focus on vulnerable communities or populations. Significant contributions have been made to the development of concepts, methods, and applications for CRA over the past decade. Work in both human health and ecological cumulative risk has advanced in two different contexts. The first context is the effects of chemical mixtures that share common modes of action, or that cause common adverse outcomes. In this context two primary models are used for predicting mixture effects, dose addition or response addition. The second context is evaluating the combined effects of chemical and nonchemical (e.g., radiation, biological, nutritional, economic, psychological, habitat alteration, land-use change, global climate change, and natural disasters) stressors. CRA can be adapted to address risk in many contexts, and this adaptability is reflected in the range in disciplinary perspectives in the published literature. This article presents the results of a literature search and discusses a range of selected work with the intention to give a broad overview of relevant topics and provide a starting point for researchers interested in CRA applications.