Carbon monoxide exposures in New York City following Hurricane Sandy in 2012.

CONTEXT: On October 29, 2012, Hurricane Sandy made landfall and devastated New York's metropolitan area, causing widespread damage to homes and the utility infrastructure. Eight days later, snow and freezing temperatures from a nor'easter storm delayed utility restoration. OBJECTIVE: To examine carbon monoxide (CO) exposures in the 2 weeks following Hurricane Sandy. Methods. This was a retrospective review of prospectively collected, standardized, and de-identified data sets. CO exposures and poisonings identified from two electronic surveillance systems, the New York City Poison Control Center (NYCPCC) and New York City's Syndromic Surveillance Unit, were compared with CO exposures from identical dates in 2008-2011. Data collected from the poison center included exposure type, CO source, poisoning type, treatment, and outcomes. Data collected from the Syndromic Surveillance Unit cases, which were identified by CO-related chief complaints presenting to NYC hospitals, included visit date and time, and patient demographics. RESULTS: Four hundred thirty-seven CO exposures were reported to the NYCPCC, 355 from NYC callers, and the remainder from surrounding counties, which represented a significant increase when compared with CO exposures from identical dates in the preceding 4 years (p < 0.001). The total cases that were reported to the NYCPCC in 2008, 2009, 2010, and 2011 were 18, 13, 24, and 61, respectively. Excluding a single apartment fire that occurred (n = 311), the more common sources of CO were grilling indoors (26.2%) and generators (17.5%). Syndromic surveillance captured 70 cases; 6 cases were captured by both data sets. CONCLUSIONS: CO exposures following weather-related disasters are a significant public health concern, and the use of fuel-burning equipment is a clear source of storm-related morbidity and mortality. Multiple real-time epidemiologic surveillance tools are useful in estimating the prevalence of CO exposure and poisoning and are necessary to assist public health efforts to prevent CO poisoning during and after disasters.

Sociodemographic correlates of indoor allergen sensitivity among United States children.

BACKGROUND: Exposure to indoor allergens is associated with asthma morbidity. Nationally, asthma morbidity disproportionately affects socially disadvantaged populations, but it is unclear whether exposure to indoor allergens follows a similar pattern. OBJECTIVE: We sought to examine the national prevalences and demographic correlates of sensitivity to indoor allergens related to asthma. METHODS: Analysis of a cross-sectional survey of a representative sample of 4164 United States children aged 6 to 16 years who participated in allergen testing in the Third National Health and Nutrition Examination Survey from 1988 to 1994 was performed. The main outcome measures were sensitivity reactions to cockroach, dust mite, cat, and Alternaria alternata, as measured via skin prick testing. RESULTS: Multivariate models, including sex, age, race-ethnicity, education, poverty, family history, region of country, housing age, crowding, and urban residence, revealed significant racial-ethnic disparities in sensitivity. Compared with white children, African American children had higher odds ratios (ORs) of cockroach or dust mite sensitivity (cockroach OR, 2.5 [95% CI, 1.9-3.2]; dust mite OR, 1.3 [95% CI, 1.0-1.7]), as did Mexican American children (cockroach OR, 1.9 [95% CI, 1.3-2.8]; dust mite OR, 1.6 [95% CI, 1.2-2.2]). African American children also had significantly higher odds of sensitivity to A alternata (OR, 2.1 [95% CI, 1.5-2.8]). CONCLUSIONS: African American and Mexican American children are substantially more likely than white children to be sensitized to allergens important in asthma. Differences in indoor allergen sensitivity are consistent with racial differences in asthma morbidity. Along with other data, these findings suggest that racial disparities in housing, community, or both environmental factors play a role in determining national patterns of asthma morbidity.

Stability and change in children's intelligence quotient scores: a comparison of two socioeconomically disparate communities.

The authors estimated the influence of familial factors and community disadvantage on changes in children's intelligence quotient (IQ) scores from age 6 years to age 11 years. Data were obtained from a longitudinal study of the neuropsychiatric sequelae of low birth weight in two socioeconomically disparate, geographically defined communities in the Detroit, Michigan, metropolitan area. Representative samples of low birth weight and normal birth weight children from the City of Detroit (urban) and nearby middle-class suburbs (suburban) were assessed at age 6 years (in 1990-1992) and age 11 years (in 1995-1997) (n = 717). Children's IQs were measured using the Wechsler Intelligence Scale for Children-Revised. The familial factors considered included maternal IQ, education, and marital status. Multiple regression analysis applying generalized estimating equations was used. The IQs of urban children, regardless of birth weight, declined from age 6 years to age 11 years. The downward shift increased by 50% the proportion of urban children scoring 1 standard deviation below the standardized IQ mean of 100. A negligible change was observed in suburban children. Maternal IQ, education, and marital status and low birth weight predicted IQ at age 6 years but were unrelated to IQ change. Growing up in a racially segregated and disadvantaged community, more than individual and familial factors, may contribute to a decline in IQ score in the early school years.

Influence of variation in birth weight within normal range and within sibships on IQ at age 7 years: cohort study.

OBJECTIVE: To examine the relation between birth weight and measured intelligence at age 7 years in children within the normal range of birth weight and in siblings. DESIGN: Cohort study of siblings of the same sex. SETTING: 12 cities in the United States. SUBJECTS: 3484 children of 1683 mothers in a birth cohort study during the years 1959 through 1966. The sample was restricted to children born at >/=37 weeks gestation and with birth weights of 1500-3999 g. MAIN OUTCOME MEASURE: Full scale IQ at age 7 years. RESULTS: Mean IQ increased monotonically with birth weight in both sexes across the range of birth weight in a linear regression analysis of one randomly selected sibling per family (n= 1683) with adjustment for maternal age, race, education, socioeconomic status, and birth order. Within same sex sibling pairs, differences in birth weight were directly associated with differences in IQ in boys (812 pairs, predicted IQ difference per 100 g change in birth weight =0.50, 95% confidence interval 0.28 to 0.71) but not girls (871 pairs, 0.10, -0.09 to 0.30). The effect in boys remained after differences in birth order, maternal smoking, and head circumference were adjusted for and in an analysis restricted to children with birth weight >/= 2500 g. CONCLUSION: The increase in childhood IQ with birth weight continues well into the normal birth weight range. For boys this relation holds within same sex sibships and therefore cannot be explained by confounding from family social environment.

Evaluation of blood lead proficiency testing: comparison of open and blind paradigms.

BACKGROUND: Most proficiency testing (PT) programs operate with an open design in which clearly identified performance samples are distributed directly to participating laboratories on a shipping schedule announced in advance. In this study, we examine the effectiveness of assessing clinical laboratory performance for blood lead with an open PT by comparing its results with a double-blinded testing protocol. METHODS: Aliquots from up to 72 blood lead performance pools from the New York State Department of Health and the Wisconsin State Laboratory of Hygiene were disguised as routine patient specimens and submitted in two phases to up to 42 certified clinical laboratories for blood lead analysis. These 42 laboratories also received aliquots of the same performance samples for blood lead analysis directly from the "open" PT program provider. RESULTS: Data reported under blind and open strategies were scored against acceptable target ranges using the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88) criteria established for blood lead, i.e., +/- 0.19 micromol/L (+/- 4 microg/dL) or +/- 10%, whichever is greater. Performance differences between the strategies were also assessed. We found that 17.7% of all blind PT results were classified as unacceptable compared with only 4.5% of open PT results (P <0.001). In phase 1, 13 of 22 laboratories (60%) exhibited a statistically significant difference (P <0.05) between their blind and open PT performances, although for 6 laboratories the poorer blind performance may not necessarily have led to unsuccessful PT participation under CLIA '88 criteria. Seven (32%) laboratories had unsuccessful aggregate performance (<80%) under blind testing while maintaining successful performance in open testing. Of these seven, two had gross discrepancies motivating further investigation. CONCLUSIONS: The data suggest that although approximately 60% of clinical laboratories make special efforts to improve analytical performance on open PT samples relative to performance achieved for routine patient specimens, in most cases the differences are clinically insignificant and would not likely affect cumulative PT performance. Occasional use of blind PT may deter the inclination to treat performance samples more carefully.

The rationale for a national prospective cohort study of environmental exposure and childhood development.

Evidence is growing that pre- and perinatal exposures and factors play a role in not only childhood but adulthood disorders. Therefore, there is a compelling need to undertake a national cohort study to evaluate the effects of such factors, ideally through adult life. Several recent developments, including advancements in computer technology, the management, storage, and analysis of biological specimens, and the rapid growth of genetic markers, facilitate the evaluation of the influence of environmental exposures on the subsequent risk of developmental abnormalities and disease. The rationale behind the establishment of such a cohort is discussed.

Medication use among children with asthma in East Harlem.

PURPOSE: To examine daily use of antiinflammatory medication among children with asthma in East Harlem, where hospitalization rates for asthma are among the highest in the United States. METHODS: We analyzed parent/guardian reports of medications used by children with current asthma (defined as physician diagnosis and wheezing during the previous 12 months) identified from a cross-sectional survey conducted in 2 elementary schools. RESULTS: From an overall sample of 1319 children, 298 with current asthma were included in this analysis. Most of those with asthma were Puerto Rican (136 [46%]) or black (98 [33%]), 168 (57%) were boys, and the median age was 8 years old. Overall, 65 (22%) were using antiinflammatory medication on a daily basis. A subgroup of 107 children with asthma had been hospitalized during the previous 12 months or had used beta(2)-agonist on a daily basis, suggesting persistent or severe asthma. Of these 107 children, 42 (39%) were taking antiinflammatory medication on a daily basis. Multivariate analysis of these 107 children revealed that daily use of antiinflammatory medication was associated with using a spacer tube (adjusted odds ratio [AOR]: 3. 08; 95% confidence interval [CI]: 1.27,7.47) and having seen a physician in the past 6 months (AOR: 3.46; CI: 1.01,11.9). Compared with Puerto Ricans, blacks (AOR:.32; CI:.12,.89) or children of other races/ethnicities (AOR:.27; CI:.09,.85) were less likely to use antiinflammatory medication on a daily basis. CONCLUSION: Daily use of antiinflammatory medication for children with persistent or severe asthma in East Harlem was underused. Differences in access to care may explain some findings; however, reasons for ethnic differences in use remain unclear. Both community interventions and additional provider education are needed.

Housing and health--current issues and implications for research and programs.

This article provides an overview of the ways in which the home environment can affect human health, describes how specific health hazards in housing are related, and considers implications of these concerns for research and programs to address the health-housing connection. The widespread availability of decent housing has contributed greatly to improvements in health status in developed countries through, for example, provision of safe drinking water, proper sewage disposal, and protection from the elements. However, a lack of decent housing and homelessness among a significant number of Americans remains a significant public health concern. In addition, a number of specific health hazards can be found even in housing that is in good condition and provides all basic amenities. Specific health hazards related to housing include unintentional injuries, exposure to lead, exposure to allergens that may cause or worsen asthma, moisture and fungi (mold), rodent and insect pests, pesticide residues, and indoor air pollution. A number of these specific hazards share underlying causes, such as excess moisture, and all may be influenced by factors in the community environment or by occupant behaviors. We make recommendations for developing programs and research efforts that address multiple housing problems in an integrated way, rather than categorically, and for closer collaboration between housing and public health programs.

Elevated blood lead levels and blood lead screening among US children aged one to five years: 1988-1994.

OBJECTIVES: To estimate the proportion of children 1 to 5 years of age who received blood lead testing during 1988-1994 and to assess whether predictors of testing coincided with predictors of elevated blood lead levels. DESIGN: Cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey. Participants. US children 1 to 5 years of age. Outcome Measures. Prevalence of blood lead testing and elevated blood lead levels among children 1 to 5 years of age and odds ratios for factors predicting blood lead testing and elevated blood lead levels. RESULTS: Overall, 6.3% had elevated blood lead levels and 10.2% had undergone previous blood lead tests. Being of minority race/ethnicity, living in an older home, residing in the Northeast or Midwest regions of the United States, being on Medicaid, having a head of household with <12 years of education, and having a history of anemia were significant factors in both models. Additional independent risk factors for an elevated blood lead level included being sampled in phase 1 of the survey, being 1 to 2 years of age, not having a regular doctor, and being sampled during the summer months. Additional independent correlates of a previous blood lead test included having moved less than twice in one's lifetime, having a female head of household, and having parents whose home language was English. Of an estimated 564 000 children 1 to 5 years of age who had elevated blood lead levels and no previous screening test in 1993, 62% were receiving Medicaid, 40% lived in homes built before 1946, and 34% were black, non-Hispanic. CONCLUSIONS: Lead screening was more frequent among children with risk factors for lead exposure. However, among children with elevated blood lead levels, only one third had been tested previously. In 1993 an estimated 564 000 children 1 to 5 years of age had elevated blood lead levels but were never screened. Physicians should screen Medicaid-eligible children and should follow state or local health department recommendations about identifying and screening other at-risk children. In areas where no health department guidelines exist, physicians should screen all children or screen based on known risk factors.

Children in Illinois with elevated blood lead levels, 1993-1998, and lead-related pediatric hospital admissions in Illinois, 1993-1997.

OBJECTIVE: This study uses screening and hospitalization data to describe the prevalence of childhood lead poisoning in Chicago and the rest of the state of Illinois. METHODS: The authors used aggregate data published by the Illinois Department of Public Health on blood lead testing of children ages 0-6 years and data on lead-related hospital admissions of children ages 0-6 years, drawn from an administrative dataset compiled as part of a state initiative. RESULTS: No clear time trends in the percentage of children with elevated blood lead levels (defined as >15 micrograms per deciliter [microg/dL] or >45 microg/dL) were evident in either Chicago or the rest of Illinois. The proportions of children with elevated blood lead levels in Chicago and in the rest of Illinois did not decline at the dramatic rate seen in the US as a whole during the 1990s. Over a five-year period, in-hospital charges of $7.7 million were generated for the care of lead-poisoned children ages 6-16 in Chicago alone. CONCLUSION: Surveillance data, analyzed at the appropriate geographic level, can be used to focus resources on high-risk areas and to evaluate prevention efforts.

Prenatal factors and adult mental and physical health.

OBJECTIVE: To review research on prenatal influences on adult mental and physical health and draw implications for future directions in psychiatric research. METHOD: Schizophrenia is selected as an example from mental health and cardiovascular disease as an example from physical health. For each of these disorders, empirical findings on prenatal influences are reviewed, and the methods used to demonstrate them are critiqued. RESULTS: Research on prenatal antecedents of these conditions has proceeded in parallel: intriguing findings have related fetal growth restriction or fetal insult to adult health; similar types of causal pathways have been proposed to explain the relationships; and research has been plagued by similar limitations, including lack of precise prenatal exposure data and difficulty of controlling confounding. The prevailing view of disease causation, which is not well-suited to investigation of prenatal antecedents, impedes research in both fields. Yet, there has been little interchange between researchers in the 2 fields. CONCLUSIONS: We propose a causal paradigm that could serve as a guide for future investigations on the prenatal antecedents of adult health and promote interchange between research on mental and physical health. The paradigm reflects current thinking in epidemiology by encompassing not only risk factors as traditionally conceived but also causal chains over time and causal influences at multiple levels of organization. Implications for the design of new research are illustrated with reference to an ongoing study.

Pesticides and inner-city children: exposures, risks, and prevention.

Six million children live in poverty in America's inner cities. These children are at high risk of exposure to pesticides that are used extensively in urban schools, homes, and day-care centers for control of roaches, rats, and other vermin. The organophosphate insecticide chlorpyrifos and certain pyrethroids are the registered pesticides most heavily applied in cities. Illegal street pesticides are also in use, including tres pasitos (a carbamate), tiza china, and methyl parathion. In New York State in 1997, the heaviest use of pesticides in all counties statewide was in the urban boroughs of Manhattan and Brooklyn. Children are highly vulnerable to pesticides. Because of their play close to the ground, their hand-to-mouth behavior, and their unique dietary patterns, children absorb more pesticides from their environment than adults. The long persistence of semivolatile pesticides such as chlorpyrifos on rugs, furniture, stuffed toys, and other absorbent surfaces within closed apartments further enhances urban children's exposures. Compounding these risks of heavy exposures are children's decreased ability to detoxify and excrete pesticides and the rapid growth, development, and differentiation of their vital organ systems. These developmental immaturities create early windows of great vulnerability. Recent experimental data suggest, for example, that chlorpyrifos may be a developmental neurotoxicant and that exposure in utero may cause biochemical and functional aberrations in fetal neurons as well as deficits in the number of neurons. Certain pyrethroids exert hormonal activity that may alter early neurologic and reproductive development. Assays currently used for assessment of the toxicity of pesticides are insensitive and cannot accurately predict effects to children exposed in utero or in early postnatal life. Protection of American children, and particularly of inner-city children, against the developmental hazards of pesticides requires a comprehensive strategy that monitors patterns of pesticide use on a continuing basis, assesses children's actual exposures to pesticides, uses state-of-the-art developmental toxicity testing, and establishes societal targets for reduction of pesticide use.

The contribution of lead-contaminated house dust and residential soil to children's blood lead levels. A pooled analysis of 12 epidemiologic studies.

In 1992, the U.S. Congress passed the Residential Lead-Based Paint Hazard Reduction Act, which requires the promulgation of health-based dust lead and soil lead standards for residential dwellings to prevent undue lead exposure in children. Unfortunately, the levels of lead in house dust and soil that are associated with elevated blood lead levels among U.S. children remain poorly defined. This pooled analysis was done to estimate the contributions of lead-contaminated house dust and soil to children's blood lead levels. The results of this pooled analysis, the most comprehensive existing epidemiologic analysis of childhood lead exposure, confirm that lead-contaminated house dust is the major source of lead exposure for children. These analyses further demonstrate that a strong relationship between interior dust lead loading and children's blood lead levels persists at dust lead levels considerably below the U.S. Department of Housing and Urban Development's current postabatement standards and the Environmental Protection Agency's guidance levels. Finally, these analyses demonstrate that a child's age, race, mouthing behaviors, and study-site specific factors influence the predicted blood lead level at a given level of exposure. These data can be used to estimate the potential health impact of alternative health-based lead standards for residential sources of lead exposure.

Accuracy and reproducibility of blood lead testing in commercial laboratories.

OBJECTIVE: To assess the proficiency of commercial laboratories in analyzing lead in clinical blood samples from subjects without overt lead exposure. DESIGN: We submitted masked duplicate blood lead specimens to 8 masked laboratories. Each laboratory received blood aliquots immediately following drawing (time 1) and 2 weeks later (time 2) from 7 human subjects and 3 bovine blood samples with known lead levels of 0.26, 0.57, and 0.79 micromol/L (5.4, 11.8, and 16.4 microg/dL). Of the 8 laboratories, 5 were commercial laboratories, 1 was a state laboratory, 1 was a research laboratory, and 1 was the Centers for Disease Control and Prevention reference laboratory. OUTCOME MEASURES: Correlation coefficients were calculated, and differences within and between laboratories were assessed by analysis of variance. RESULTS: Results were obtained for all specimens, with all the human subjects' overall mean lead levels being less than 0.48 micromol/L (<10 microg/dL). Each laboratory reported all human blood specimens appropriately, as having lead levels less than 0.48 micromol/L (<10 microg/dL) and within 0.14 micromol/L (3 microg/dL) of the overall mean for that subject. All internal reproducibilities were very high (range, 0.92-1.00) except for one (0.60), possibly lower because of 1 pair of specimens. Mean differences between blood samples analyzed at time 1 and time 2 ranged from -1.4 to 1.2, with only 2 laboratories having significant differences (P<.01). CONCLUSIONS: Overall, there was strong reproducibility within and among laboratories, with no overall time trend or interlaboratory or intralaboratory variance. The storage conditions did not seem to affect the aggregate results. The data suggest that through implementation of the Centers for Disease Control and Prevention/Wisconsin Blood Lead Proficiency Testing Program, the Centers for Disease Control and Prevention's Blood Lead Laboratory Reference System, and mandated federal and state proficiency programs, laboratories in this geographic region have improved their performance as compared with previous published studies and an unpublished study.

Elevated blood lead levels in children of construction workers.

OBJECTIVES: This study examined whether children of lead-exposed construction workers had higher blood lead levels than neighborhood control children. METHODS: Twenty-nine construction workers were identified from the New Jersey Adult Blood Lead Epidemiology and Surveillance (ABLES) registry. Eighteen control families were referred by workers. Venous blood samples were collected from 50 children (31 exposed, 19 control subjects) under age 6. RESULTS: Twenty-six percent of workers children had blood lead levels at or over the Centers for Disease Control and Prevention action level of 0.48 mumol/L (10 micrograms/dL), compared with 5% of control children (unadjusted odds ratio = 6.1; 95% confidence interval = 0.9, 147.2). CONCLUSIONS: Children of construction workers may be at risk for excessive lead exposure. Health care providers should assess parental occupation as a possible pathway for lead exposure of young children.

Lead Exposure among Adult Temporary Residents in Eastern Europe: Should Blood Lead Levels Be Monitored?

Background: The risk of lead exposure among temporary residents in Eastern Europe is unknown. We monitored blood lead levels (BLLs) of Peace Corps Volunteers serving in Albania, Bulgaria, the Czech Republic, Hungary, Poland, Romania, and Slovakia from June 1991 through June 1994. Methods: BLLs were analyzed before the Volunteers left the United States (Sample 1), at mid-service (median of 15 months in-country, Sample 2), and at end-of-service (median of 22 months in-country, Sample 3). Results: Among 425 study participants who provided at least one follow-up blood sample, BLLs were significantly higher at Samples 2 and 3 compared to the U.S. baseline (paired t-test, p<.0001); however, the mean increase in BLL was only 1.0 ug/dL (range = -9.6 to 10.7). Overall, 74% of Volunteers experienced an increase in BLLs, 24% a decrease in BLLs, and 2% no change in BLLs at Sample 3 compared to their U.S. baseline. The highest increases in BLLs were among Volunteers in Albania, Bulgaria, and Romania (analysis of variance, p<.0001). In addition, men had higher mean increases in BLLs at Samples 2 and 3 compared to women (t-test, p=.017 and.029). Conclusions: The risk of significant lead exposure among our study population was low, and monitoring of BLLs among adult short-term residents in Eastern Europe does not seem to be indicated.

Lead-contaminated house dust and urban children's blood lead levels.

OBJECTIVES: This study assessed the relationship between lead-contaminated house dust and urban children's blood lead levels. METHODS: A random-sample survey was used to identify and enroll 205 children, 12 to 31 months of age, who had resided in the same house since at least 6 months of age. Children's blood and household dust, water, soil, and paint were analyzed for lead, and interviews were conducted to ascertain risk factors for elevated blood lead (> or = 10 micrograms/dL). RESULTS: Children's mean blood lead level was 7.7 micrograms/dL. In addition to dust lead loading (micrograms of lead per square foot), independent predictors of children's blood lead were Black race, soil lead levels, ingestion of soil or dirt, lead content and condition of painted surfaces, and water lead levels. For dust lead standards of 5 micrograms/sq ft, 20 micrograms/sq ft, and 40 micrograms/sq ft on noncarpeted floors, the estimated percentages of children having blood lead levels at or above 10 micrograms/dL were 4%, 15%, and 20%, respectively, after adjusting for other significant covariates. CONCLUSIONS: Lead-contaminated house dust is a significant contributor to lead intake among urban children who have low-level elevations in blood lead. A substantial proportion of children may have blood lead levels of at least 10 micrograms/dL at dust lead levels considerably lower than current standards.