Harmful Algal Bloom Exposures Self-reported to Poison Centers in the United States, May-October 2019.

The National Poison Data System (NPDS) comprises self-reported information from people who call US poison center hotlines. NPDS data have proven to be important in identifying emerging public health threats. We used NPDS to examine records of people who had self-reported exposure to harmful algal blooms (HABs). Participating poison centers then contacted people who had called their centers from May through October 2019 about their HAB exposure to ask about exposure route, symptoms, health care follow-up, and awareness of possible risks of exposure. Of 55 callers who agreed to participate, 47 (85%) reported exposure to HABs while swimming or bathing in HAB-contaminated water. Nine callers reported health symptoms from being near waters contaminated with HABs, suggesting potential exposure via aerosolized toxins. Symptoms varied by the reported routes of exposure; the most commonly reported symptoms were gastrointestinal and respiratory. More public and health care provider education and outreach are needed to improve the understanding of HAB-related risks, to address ways to prevent HAB-related illnesses, and to describe appropriate support when exposures occur.

Severe illness associated with reported use of synthetic cannabinoids: a public health investigation (Mississippi, 2015).

STUDY OBJECTIVES: In April 2015, a multistate outbreak of illness linked to synthetic cannabinoid (SC) use was unprecedented in magnitude and severity. We identified Mississippi cases in near-real time, collected information on cases to characterize the outbreak, and identified the causative SC. METHODS: A case was defined as any patient of a Mississippi healthcare facility who was suspected of SC use and presenting with ≥2 of the following symptoms: sweating, severe agitation, or psychosis during April 2-May 3, 2015. Clinicians reported cases to the Mississippi Poison Control Center (MPCC). We used MPCC data to identify cases at the University of Mississippi Medical Center (UMMC) to characterize in further detail, including demographics and clinical findings. Biologic samples were tested for known and unknown SCs by liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF/MS). RESULTS: Clinicians reported 721 cases (11 deaths) statewide; 119 (17%) were UMMC patients with detailed data for further analysis. Twelve (10%) were admitted to an intensive care unit and 2 (2%) died. Aggression (32%), hypertension (33%), and tachycardia (42%) were common. SCs were identified in serum from 39/56 patients (70%); 33/39 patients (85%) tested positive for MAB-CHMINACA (N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide) or its metabolites. Compared to all patients tested for SCs, those positive for MAB-CHMINACA were more likely to have altered mental status on examination (OR = 3.3, p = .05). CONCLUSION: SC use can cause severe health effects. MAB-CHMINACA was the most commonly detected SC in this outbreak. As new SCs are created, new strategies to optimize surveillance and patient care are needed to address this evolving public health threat.

Human aflatoxin albumin adducts quantitatively compared by ELISA, HPLC with fluorescence detection, and HPLC with isotope dilution mass spectrometry.

Essential to the conduct of epidemiologic studies examining aflatoxin exposure and the risk of heptocellular carcinoma, impaired growth, and acute toxicity has been the development of quantitative biomarkers of exposure to aflatoxins, particularly aflatoxin B(1). In this study, identical serum sample sets were analyzed for aflatoxin-albumin adducts by ELISA, high-performance liquid chromatography (HPLC) with fluorescence detection (HPLC-f), and HPLC with isotope dilution mass spectrometry (IDMS). The human samples analyzed were from an acute aflatoxicosis outbreak in Kenya in 2004 (n = 102) and the measured values ranged from 0.018 to 67.0, nondetectable to 13.6, and 0.002 to 17.7 ng/mg albumin for the respective methods. The Deming regression slopes for the HPLC-f and ELISA concentrations as a function of the IDMS concentrations were 0.71 (r(2) = 0.95) and 3.3 (r(2) = 0.96), respectively. When the samples were classified as cases or controls, based on clinical diagnosis, all methods were predictive of outcome (P < 0.01). Further, to evaluate assay precision, duplicate samples were prepared at three levels by dilution of an exposed human sample and were analyzed on three separate days. Excluding one assay value by ELISA and one assay by HPLC-f, the overall relative SD were 8.7%, 10.5%, and 9.4% for IDMS, HPLC-f, and ELISA, respectively. IDMS was the most sensitive technique and HPLC-f was the least sensitive method. Overall, this study shows an excellent correlation between three independent methodologies conducted in different laboratories and supports the validation of these technologies for assessment of human exposure to this environmental toxin and carcinogen.

Exogenous and endogenous determinants of blood trihalomethane levels after showering.

BACKGROUND: We previously conducted a study to assess whether household exposures to tap water increased an individual's internal dose of trihalomethanes (THMs). Increases in blood THM levels among subjects who showered or bathed were variable, with increased levels tending to cluster in two groups. OBJECTIVES: Our goal was to assess the importance of personal characteristics, previous exposures, genetic polymorphisms, and environmental exposures in determining THM concentrations in blood after showering. METHODS: One hundred study participants completed a health symptom questionnaire, a 48-hr food and water consumption diary, and took a 10-min shower in a controlled setting. We examined THM levels in blood samples collected at baseline and 10 and 30 min after the shower. We assessed the significance of personal characteristics, previous exposures to THMs, and specific gene polymorphisms in predicting postshower blood THM concentrations. RESULTS: We did not observe the clustering of blood THM concentrations observed in our earlier study. We found that environmental THM concentrations were important predictors of blood THM concentrations immediately after showering. For example, the chloroform concentration in the shower stall air was the most important predictor of blood chloroform levels 10 min after the shower (p < 0.001). Personal characteristics, previous exposures to THMs, and specific polymorphisms in CYP2D6 and GSTT1 genes were significant predictors of both baseline and postshowering blood THM concentrations as well as of changes in THM concentrations associated with showering. CONCLUSION: The inclusion of information about individual physiologic characteristics and environmental measurements would be valuable in future studies to assess human health effects from exposures to THMs in tap water.

Recreational exposure to low concentrations of microcystins during an algal bloom in a small lake.

We measured microcystins in blood from people at risk for swallowing water or inhaling spray while swimming, water skiing, jet skiing, or boating during an algal bloom. We monitored water samples from a small lake as a Microcystis aeruginosa bloom developed. We recruited 97 people planning recreational activities in that lake and seven others who volunteered to recreate in a nearby bloom-free lake. We conducted our field study within a week of finding a 10-microg/L microcystin concentration. We analyzed water, air, and human blood samples for water quality, potential human pathogens, algal taxonomy, and microcystin concentrations. We interviewed study participants for demographic and current health symptom information. Water samples were assayed for potential respiratory viruses (adenoviruses and enteroviruses), but none were detected. We did find low concentrations of Escherichia coli, indicating fecal contamination. We found low levels of microcystins (2 microg/L to 5 microg/L) in the water and (<0.1 ng/m(3)) in the aerosol samples. Blood levels of microcystins for all participants were below the limit of detection (0.147 microg/L). Given this low exposure level, study participants reported no symptom increases following recreational exposure to microcystins. This is the first study to report that water-based recreational activities can expose people to very low concentrations of aerosol-borne microcystins; we recently conducted another field study to assess exposures to higher concentrations of these algal toxins.

Investigating childhood leukemia in Churchill County, Nevada.

BACKGROUND: Sixteen children diagnosed with acute leukemia between 1997 and 2002 lived in Churchill County, Nevada, at the time of or before their illness. Considering the county population and statewide cancer rate, fewer than two cases would be expected. OBJECTIVES: In March 2001, the Centers for Disease Control and Prevention led federal, state, and local agencies in a cross-sectional, case-comparison study to determine if ongoing environmental exposures posed a health risk to residents and to compare levels of contaminants in environmental and biologic samples collected from participating families. METHODS: Surveys with more than 500 variables were administered to 205 people in 69 families. Blood, urine, and cheek cell samples were collected and analyzed for 139 chemicals, eight viral markers, and several genetic polymorphisms. Air, water, soil, and dust samples were collected from almost 80 homes to measure more than 200 chemicals. RESULTS: The scope of this cancer cluster investigation exceeded any previous study of pediatric leukemia. Nonetheless, no exposure consistent with leukemia risk was identified. Overall, tungsten and arsenic levels in urine and water samples were significantly higher than national comparison values; however, levels were similar among case and comparison groups. CONCLUSIONS: Although the cases in this cancer cluster may in fact have a common etiology, their small number and the length of time between diagnosis and our exposure assessment lessen the ability to find an association between leukemia and environmental exposures. Given the limitations of individual cancer cluster investigations, it may prove more efficient to pool laboratory and questionnaire data from similar leukemia clusters.

Heat-related mortality during a 1999 heat wave in Chicago.

BACKGROUND: During the summer of 1999, Chicago's second deadliest heat wave of the decade resulted in at least 80 deaths. The high mortality, exceeded only by a 1995 heat wave, provided the opportunity to investigate the risks associated with heat-related deaths and to examine the effectiveness of targeted heat-relieving interventions. METHODS: We conducted a case-control study to determine risk factors for heat-related death. We collected demographic, health, and behavior information for 63 case patients and 77 neighborhood-and-age-matched control subjects and generated odds ratios (ORs) for each potential risk factor. RESULTS: Fifty-three percent of the case patients were aged <65 years, and psychiatric illness was almost twice as common in the younger than the older age group. In the multivariate analysis, the strongest risk factors for heat-related death were living alone (OR=8.1; 95% confidence interval [CI], 1.4-48.1) and not leaving home daily (OR=5.8; 95% CI, 1.5-22.0). The strongest protective factor was a working air conditioner (OR=0.2; 95% CI, 0.1-0.7). Over half (53%) of the 80 decedents were seen or spoken to on the day of or day before their deaths. CONCLUSIONS: A working air conditioner is the strongest protective factor against heat-related death. The relatively younger age of case patients in 1999 may be due to post-1995 interventions that focused on the elderly of Chicago. However, social isolation and advanced age remain important risk factors. Individual social contacts and educational messages targeted toward at-risk populations during heat waves may decrease the number of deaths in these groups.

Investigation of the relation between self-reported food consumption and household chemical exposures with urinary levels of selected nonpersistent pesticides.

Concerns about pesticide exposure through food consumption have increased during the past several years. The main objective of our study was to determine whether we could use data from the Third National Health and Nutrition Examination Survey (NHANES III) to detect a relation between self-reported food consumption--particularly consumption of fruits, vegetables, and bread products--and urinary levels of pesticides or their metabolites in a population of 978 adults living in the US. A secondary objective was to investigate whether these urine levels differed for people who reported exposure to selected common household chemicals including bug or insect spray, weed killer, and mothballs or crystals. We used monthly food frequency data from the NHANES III, 1988-1994. Urinary pesticide/metabolite levels and information about chemical exposures were taken from the Priority Toxicant Reference Range Study (a component of the NHANES III). Six pesticides or their metabolites were detected in at least 50% of the sample, three of which--1-naphthol (86.4%), pentachlorophenol (62.5%), and 3,5,6-trichloro-2-pyridinol (82.0%)--were possibly related to food consumption. We were unable to detect a relation between self-reported food consumption and their urinary levels. This may be due more to the limitations of the datasets than to a lack of a relation between food consumption and urine pesticide/metabolite levels. We did find that people who reported recently using selected common chemicals had higher geometric mean urine pesticide/metabolite levels than did people who reported not recently using these chemicals.

Stature and pubertal stage assessment in American boys: the 1988-1994 Third National Health and Nutrition Examination Survey.

PURPOSE: To describe current stature and pubertal development in North American boys, and to compare these measures with measures observed approximately 30 years ago. METHODS: We analyzed data (i.e., height, weight, and Tanner Stage) from the Third National Health and Nutrition Examination Survey (NHANES III), conducted between 1988-1994, and compared it to the National Health Examination Survey, Cycles II and III (HES II/III), conducted from 1963-1965 and 1966-1970. The surveys included physical examination and questionnaire components, employed cross-sectional designs, and are nationally representative. We used logistic regression to calculate median age at onset of pubertal stages. RESULTS: NHANES III included 2481 boys aged 8 to 18 years. HES II comprised 3010 boys aged 8-11 years and HES III comprised 3514 boys aged 12-17 years. The mean heights of the oldest boys in both surveys did not differ significantly; however, at younger ages, boys in the more recent survey were taller (average height difference among those aged 8-14 years was 2.0 cm). Boys in NHANES III were also heavier and had higher body mass index than those in HES II/III. The median estimated ages of onset of pubertal stages in NHANES III were 9.9, 12.2, 13.6, and 15.8 years for genital stages 2-5, respectively, and 11.9, 12.6, 13.6, and 15.7 years for pubic hair stages 2-5, respectively. For some stages, the median estimated age of onset of puberty was earlier among boys in NHANES III than among those in HES III. CONCLUSIONS: Differences in mean height at young ages, but not at older ages, suggest that the rate of growth among boys in NHANES III was faster than that of boys in the earlier surveys. This finding, coupled with the finding of earlier ages of onset of some pubertal stages, suggests that boys of this generation may be maturing more rapidly than did boys in the past.

Serum selenium levels in the US population: Third National Health and Nutrition Examination Survey, 1988-1994.

The published literature on serum selenium levels in the US population describes studies on small samples that may not be representative of the US population. This analysis provides the first nationally representative serum selenium levels in the US population by age group, sex, race-ethnicity, poverty income ratio (PIR), geographic region, and urban status. The Third National Health and Nutrition Examination Survey (NHANES III) is a national population-based cross-sectional survey with an in-person interview and serum selenium measurements. For the 18,597 persons for whom serum selenium values wereavailable in NHANES III, the mean concentration was 1.58 nmol/L and the median concentration was 1.56 nmol/L. Mean serum selenium levels differed by age group, sex, race ethnicity, PIR, and geographic region. The US population has slight differences in serum selenium levels by demographic factors.

Case-control study of breast cancer and exposure to synthetic environmental chemicals among Alaska Native women.

BACKGROUND: Exposure to environmental chemicals may impair endocrine system function. Alaska Native (AN) women may be at higher risk of exposure to these endocrine disrupting chemicals, which may contribute to breast cancer in this population. OBJECTIVE: To measure the association between exposure to select environmental chemicals and breast cancer among AN women. DESIGN: A case-control study of 170 women (75 cases, 95 controls) recruited from the AN Medical Center from 1999 to 2002. Participants provided urine and serum samples. Serum was analyzed for 9 persistent pesticides, 34 polychlorinated biphenyl (PCB) congeners, and 8 polybrominated diethyl ether (PBDE) congeners. Urine was analyzed for 10 phthalate metabolites. We calculated geometric means (GM) and compared cases and controls using logistic regression. RESULTS: Serum concentrations of most pesticides and 3 indicator PCB congeners (PCB-138/158; PCB-153, PCB-180) were lower in case women than controls. BDE-47 was significantly higher in case women (GM=38.8 ng/g lipid) than controls (GM=25.1 ng/g lipid) (p=0.04). Persistent pesticides, PCBs, and most phthalate metabolites were not associated with case status in univariate logistic regression. The odds of being a case were higher for those with urinary mono-(2-ethylhexyl) phthalate (MEHP) concentrations that were above the median; this relationship was seen in both univariate (OR 2.16, 95% CI 1.16-4.05, p=0.02) and multivariable (OR 2.43, 95% CI 1.13-5.25, p=0.02) logistic regression. Women with oestrogen receptor (ER)-/progesterone receptor (PR)-tumour types tended to have higher concentrations of persistent pesticides than did ER+/PR+ women, although these differences were not statistically significant. CONCLUSIONS: Exposure to the parent compound of the phthalate metabolite MEHP may be associated with breast cancer. However, our study is limited by small sample size and an inability to control for the confounding effects of body mass index. The association between BDE-47 and breast cancer warrants further investigation.

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 microg/l, range: 0.68-5.05); soy-based (0.21 microg/l, range: 0.10-0.44); lactose-free (0.27 microg/l, range: 0.03-0.93); and elemental (0.18 microg/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.

Recreational exposure to microcystins during algal blooms in two California lakes.

We conducted a study of recreational exposure to microcystins among 81 children and adults planning recreational activities on either of three California reservoirs, two with significant, ongoing blooms of toxin-producing cyanobacteria, including Microcystis aeruginosa (Bloom Lakes), and one without a toxin-producing algal bloom (Control Lake). We analyzed water samples for algal taxonomy, microcystin concentrations, and potential respiratory viruses (adenoviruses and enteroviruses). We measured microcystins in personal air samples, nasal swabs, and blood samples. We interviewed study participants for demographic and health symptoms information. We found highly variable microcystin concentrations in Bloom Lakes (<10 microg/L to >500 microg/L); microcystin was not detected in the Control Lake. We did not detect adenoviruses or enteroviruses in any of the lakes. Low microcystin concentrations were found in personal air samples (<0.1 ng/m(3) [limit of detection]-2.89 ng/m(3)) and nasal swabs (<0.1 ng [limit of detection]-5 ng). Microcystin concentrations in the water-soluble fraction of all plasma samples were below the limit of detection (1.0 microg/L). Our findings indicate that recreational activities in water bodies that experience toxin-producing cyanobacterial blooms can generate aerosolized cyanotoxins, making inhalation a potential route of exposure. Future studies should include collecting nasal swabs to assess upper respiratory tract deposition of toxin-containing aerosols droplets.

Mean and median hearing thresholds among children 6 to 19 years of age: the Third National Health And Nutrition Examination Survey, 1988 to 1994, United States.

OBJECTIVE: The objective of this study was to provide the first national representative values for mean and median hearing thresholds among US children 6 to 19 yrs of age. METHODS: Hearing thresholds were obtained from 6166 children in the Third National Health and Nutrition Examination Survey (1988 to 1994), a national, population-based cross-sectional survey with household interview and audiometric testing at 0.5 to 8 kHz. Means, medians, and standard errors of the mean were obtained and reported by ear, frequency, sex, and age. RESULTS: The mean and median thresholds ranged from 3.0 to 11.8 dB HL and -1.0 to 10.8 dB HL, respectively. The highest (poorest) thresholds were obtained at test frequencies above 4000 Hz. Similar mean and median thresholds were found between boys and girls at all frequencies. CONCLUSIONS: These data indicate that the mean thresholds fall below the standard screening guidelines recommended by the American Speech-Language-Hearing Association (< or =20 dB HL for the frequencies from 1000< or =20 dB HL for the frequencies from 2000, and 4000 Hz). The results of this study suggest the need to include the test frequency of 6000 Hz in screening protocols for children.