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.

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.

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.

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.

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.

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.

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.

Integrating Health into Local Climate Response: Lessons from the U.S. CDC Climate-Ready States and Cities Initiative.

SUMMARY: Public health has potential to serve as a frame to convey the urgency of behavior change needed to adapt to a changing climate and reduce greenhouse gas emissions. Local governments form the backbone of climate-related public health preparedness. Yet local health agencies are often inadequately prepared and poorly integrated into climate change assessments and plans. We reviewed the climate health profiles of 16 states and two cities participating in the U.S. Centers for Disease Control and Prevention (CDC)'s Climate-Ready States and Cities Initiative (CRSCI) that aims to build local capacity to assess and respond to the health impacts of climate change. Following recommendations from a recent expert panel strategic review, we present illustrations of emerging promising practice and future directions. We found that CRSCI has strengthened climate preparedness and response in local public health agencies by identifying critical climate-health impacts and vulnerable populations, and has helped integrate health more fully into broader climate planning. Promising practice was found in all three recommendation areas identified by the expert panel (leveraging partnerships, refining assessment methodologies and enhancing communications), particularly with regard to health impacts of extreme heat. Vast needs remain, however, suggesting the need to disseminate CRSCI experience to non-grantees. In conclusion, the CRSCI program approach and selected activities illustrate a way forward toward robust, targeted local preparedness and response that may serve as a useful example for public health departments in the United States and internationally, particularly at a time of uncertain commitment to climate change agreements at the national level. https://doi.org/10.1289/EHP1838.

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.

Meeting the public health challenge of protecting private wells: Proceedings and recommendations from an expert panel workshop.

Private wells serving fewer than 25 people are federally unregulated, and their users may be exposed to naturally occurring agents of concern such as arsenic and radionuclides, as well as anthropogenic contaminants. The Centers for Disease Control and Prevention's Clean Water for Health Program works to protect private wells and prevent adverse health outcomes for the roughly 15% of Americans who rely on them. To understand current and emerging challenges to the private drinking water supply, an interdisciplinary expert panel workshop on "Future and Emerging Issues for Private Wells" was organized to inform strategic planning for the Clean Water for Health Program. The panel assessed current conditions of ground water as a source for private wells, identified emerging threats, critical gaps in knowledge, and public health needs, and recommended strategies to guide future activities to ensure the safety of private drinking water wells. These strategies addressed topics of broad interest to the environmental public health community including: development of new methods to support citizen science; addressing contaminant mixtures; expanding capacity for well testing; evaluating treatment technologies; building an evidence base on best practices on well owner outreach and stewardship; and research and data needs.

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.

Probabilistic modeling of school meals for potential bisphenol A (BPA) exposure.

Many endocrine-disrupting chemicals (EDCs), including bisphenol A (BPA), are approved for use in food packaging, with unbound BPA migrating into the foods it contacts. Children, with their developing organ systems, are especially susceptible to hormone disruption, prompting this research to model the potential dose of BPA from school-provided meals. Probabilistic exposure models for school meals were informed by mixed methods. Exposure scenarios were based on United States school nutrition guidelines and included meals with varying levels of exposure potential from canned and packaged food. BPA exposure potentials were modeled with a range of 0.00049 µg/kg-BW/day for a middle school student with a low exposure breakfast and plate waste to 1.19 µg/kg-BW/day for an elementary school student eating lunch with high exposure potential. The modeled BPA doses from school meals are below the current US EPA Oral Reference Dose (RfD) of 50 µg/kg-BW/day. Recent research shows BPA animal toxicity thresholds at 2 µg/kg-BW/day. The single meal doses modeled in this research are at the same order of magnitude as the low-dose toxicity thresholds, illustrating the potential for school meals to expose children to chronic toxic levels of BPA.

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.

Prospectively ECG-Triggered Sequential Dual-Source Coronary CT Angiography in Patients with Atrial Fibrillation: Influence of Heart Rate on Image Quality and Evaluation of Diagnostic Accuracy.

OBJECTIVES: To evaluate the effects of mean heart rate (HR) and heart rate variation (HRV) on image quality and diagnostic accuracy of prospectively ECG-triggered sequential dual-source coronary CT angiography (CCTA) in patients with atrial fibrillation (AF). METHODS: Eighty-five patients (49 women, 36 men; mean age 62. 1 ± 9.5 years) with persistent AF underwent prospectively ECG-triggered sequential second-generation dual-source CCTA. Tube current and voltage were adjusted according to body mass index (BMI) and iterative reconstruction was used. Image quality of coronary segments (four-point scale) and presence of significant stenosis (>50%) were evaluated. Diagnostic accuracy was analyzed in 30 of the 85 patients who underwent additional invasive coronary angiography (ICA). RESULTS: Only 8 of 1102 (0.7%) segments demonstrated poor image quality. No significant impact on image quality was found for mean HR (94.9 ± 21.8 bpm; r=0.034, p=0.758; F=0.413, p=0.663) or HRV (67.5 ± 22.8 bpm; r=0.097, p=0.377; F=0.111, p=0.895). On per-segment analysis, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 89.7% (26/29), 99.4% (355/357), 92.9% (26/28), and 99.2% (355/358), respectively, with excellent correlation (kappa=0.91) with ICA. Mean effective dose was 3.3 ± 1.0 mSv. CONCLUSIONS: Prospectively ECG-triggered sequential dual-source CCTA provides diagnostic image quality and good diagnostic accuracy for detection of coronary stenosis in AF patients without significant influence by HR or HRV.

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.

Determinants of exposure to fragranced product chemical mixtures in a sample of twins.

Fragranced product chemical mixtures may be relevant for environmental health, but little is known about exposure. We analyzed results from an olfactory challenge with the synthetic musk fragrance 1,3,4,6,7,8-hexahydro-4,6,6,7,8,8-hexamethyl-cyclopento-γ-2-benzopyran (HHCB), and a questionnaire about attitudes toward chemical safety and use of fragranced products, in a sample of 140 white and 17 black twin pairs attending a festival in Ohio. Data for each product were analyzed using robust ordered logistic regressions with random intercepts for "twin pair" and "sharing address with twin", and fixed effects for sex, age, education, and "ever being bothered by fragrances". Due to the small number of black participants, models were restricted to white participants except when examining racial differences. Overall patterns of association were summarized across product-types through random-effects meta-analysis. Principal components analysis was used to summarize clustering of product use. The dominant axis of variability in fragranced product use was "more vs. less", followed by a distinction between household cleaning products and personal care products. Overall, males used fragranced products less frequently than females (adjusted proportionate odds ratio 0.55, 95% confidence interval 0.33, 0.93). This disparity was driven by personal care products (0.42, 95% CI: 0.19, 0.96), rather than household cleaning products (0.79, 95% CI: 0.49, 1.25) and was particularly evident for body lotion (0.12, 95% CI: 0.05, 0.27). Overall usage differed by age (0.64, 95% CI: 0.43, 0.95) but only hand soap and shampoo products differed significantly. "Ever being bothered by fragrance" had no overall association (0.92, 95% CI: 0.65, 1.30) but was associated with laundry detergent use (0.46, 95% CI: 0.23, 0.93). Similarly, black vs. white differences on average were not significant (1.34, 95% CI: 0.55, 3.28) but there were apparent differences in use of shampoo (0.01, 95% CI: 0.00, 0.69), body lotion (4.67, 95% CI: 1.18, 18.47), and perfume (6.22, 95% CI:1.08, 35.89). There was no overall association with thinking about product risks (0.90, 95% CI: 0.79, 1.02), nor with inability to smell HHCB (0.84, 95% CI: 0.63, 1.12). Exposure to fragranced products may differ demographically. The relevance for health disparities should be studied.