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Environmental Health

2002

U.S. Department of Health and Human ServicesCenters for Disease Control and Prevention

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Foreword iii

Our Vision, Our Mission, and Our Partners v

The Essence of Our Environmental Health Work vii

Accomplishments 1

Success Stories 45

Key Research Findings 53

2001 Publications 71

TABLE OF CONTENTS

Environmental Health 2002

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Within these pages is a record of the activities thatengage the minds and hearts of the people of theCenters for Disease Control and Prevention (CDC)who work at the National Center for EnvironmentalHealth. It is as well an affirmation of the importancewe place on working across disciplines with a hostof governments and agencies to improve the healthof people in this country and across the globe. Theprograms we're involved with remind us on a dailybasis of the diversity of the people we serve and theproblems they face.

This book also reminds us that our predecessors atCDC were visionaries. Without their foresight, wewould be unable to do much of the work that othersnow often consider routine. However, we must bevigilant about resisting complacency, because westill have much to accomplish. In this nation alone,we will double our population during the next 100years. Among other things, this means that we mustact now to strengthen environmental healthprograms and services. It means that we will have torethink how we use our land and design ourcommunities to enhance health rather than tocontribute to its decline.

Finally, we must make sure that the work we docontinues to do two things: (1) first and foremost,that it improves the health of the people we serve,both now and in the future; and (2) that it excites theimaginations of a new generation of "CDCers." Wewant to attract dedicated professionals from manydisciplines who will see that we, as did those whocame before us, mean to keep the faith of the people we serve.

Richard Joseph Jackson, MD, MPHDirectorNational Center for Environmental Health

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FOREWORD


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OUR VISION, OUR MISSION, AND OUR PARTNERS

OUR VISIONHealthy people

in healthy communitiesfree from disease

due to the environment

OUR MISSIONTo promote healthand quality of life

by preventing or controllingthose diseases or deaths

that result from interactionsbetween people

and their environment

OUR PARTNERSState and local health departments

Other CDC centers, institute, and officesOther federal agenciesForeign governments

International health organizationsNongovernmental organizations

Academic institutionsPhilanthropic foundations

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CDC's environmental health work cuts acrossseveral centers. Here at the National Center forEnvironmental Health, we focus on the followingprogram areas:

• Safeguarding the health of people from environmental threats

• Providing leadership in the use of environmental health sciences—including environmental epidemiology, environmental sanitation, and laboratory sciences—to protect public health

• Responding and sharing solutions to environmental health problems worldwide

• Communicating information about genes, diseases, and environmental risk factors

The following paragraphs provide an overview ofdivisions and offices that are actively engaged inenvironmental health activities.

The Division of Environmental Hazards andHealth Effects (EHHE) conducts surveillance andinvestigations that increase knowledge aboutthe relation between human health and theenvironment and uses this knowledge to developnational public health programs and policiesaimed at preventing disease. EHHE studiesways to prevent or control health problemsassociated with exposure to air pollution, nuclear radiation, lead, and other toxicants, as well as

those health problems resulting from naturaland technologic disasters.

The Division of Emergency and EnvironmentalHealth Services (EEHS) provides national andinternational leadership in coordinating,delivering, and evaluating emergency andenvironmental health services. EEHS helps local,state, federal, and international agencies plan,prepare, and respond to emergencies, includingterrorist attacks, technologic accidents, andnatural disasters. EEHS also provides grants,technical assistance, scientific guidance, and insome cases, direct service delivery to state, local,and nongovernmental agencies engaged inenvironmental health services such as foodsafety, rodent control, water quality, andsanitation.

The Division of Laboratory Sciences (DLS)develops and applies laboratory science toprevent disease and death caused by exposure toenvironmental chemicals and to improve thediagnosis, treatment, and prevention of selectedchronic diseases. DLS specializes in biomonitoring,which is the assessment of individual humanexposure to environmental chemicals bymeasuring them in human specimens (e.g., bloodor urine). Biomonitoring provides valuable andunique information that guides health officials inrisk assessment, treatment, and prevention.

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The Essence of Our Environmental Health Work

The Office of Global Health works with partnersto improve health worldwide. Five globalpriorities of this office are childhood leadpoisoning prevention; water, sanitation, andhygiene; urban health and megacities;micronutrient malnutrition; and emergencypreparedness and response.

The Office of Genomics and Disease Prevention(OGDP) integrates advances in human genomediscoveries into public health research, policy,and programs. OGDP's activities focus onconducting applied research, evaluating genetictesting, disseminating information, and trainingthe public health workforce.

The work we do in environmental public health isbased on strong science and focuses on linkingenvironmental conditions with specific measuresof human health—the goal of which is todiscover specific public health interventions toimprove human health. Such meaningful efforts,which influence the quality of life of people inthis country and throughout the world, comprisethe essence of our environmental health work.


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Asthma

S tate-Specific Asthma Data MadeAvailable for the First Time Asthma’seffect on health and quality of life and on

the economy is substantial, and asthma ratesare increasing. However, there are few data

on the prevalence of the disease at thestate level or in specific populations. Tohelp address this public healthconcern, the Centers for DiseaseControl and Prevention (CDC) addedoptional asthma questions to theBehavioral Risk Factor SurveillanceSystem (BRFSS) in 1999. BRFSS is astate-based telephone survey ofnoninstitutionalized U.S. adults

18 years of age and older that measuresmodifiable risk factors for chronic

diseases and other leading causes ofdeath. In 2000, these questions were made

part of the core data collection process in all50 states, the District of Columbia, and Puerto

Rico. In August 2001, CDC published a summaryarticle in Morbidity and Mortality Weekly Report

(MMWR) (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5032a3.htm) about the data gathered with the

new questions. More extensive demographic tables have since beendeveloped and are available on the CDC Web site at http://www.cdc.gov/nceh/airpollution/asthma/brfss/default.htm. The continued use of the BRFSSasthma questions will enable state health departments to monitor trends inasthma prevalence and to better direct management efforts by providingprevalence rates for detailed demographic subgroups at the state level.

Accomplishments

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Link Studied Between Exposure to EnvironmentalTobacco Smoke in the Home and Exacerbation ofAsthma Exposure to environmental tobacco smoke(ETS) has been linked to the increased incidence,frequency, and severity of asthma among children,particularly among those from lower socioeconomic-status households. CDC examined householdsmoking behavior and ETS exposure amongpredominately ethnic minority children withasthma who live in low-income householdswhere people smoke. The study also assessedthe relation between ETS exposure evaluated byusing questionnaires and exposure determinedby assessing biomarkers (i.e., levels of cotinine, anicotine metabolite, in children’s urine). Results

indicated that in the predominately Latinopopulation surveyed during this work, the level ofexposure to ETS in the home was relatively low,and this finding was most notable in the leastacculturated (i.e., recent immigrant) families.Smoking restrictions in the home were animportant factor in reducing exposures. Thesingle variable that accounted for the greatestproportion of variance in a child’s urine cotininewas the level of smoking restriction in the home.In this work, the biomarker results agreed withenvironmental nicotine measures and also closelycorroborated the interview data, providingincreased confidence in the reliability of self-reported smoking behavior in this population.


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CDC-Funded Asthma Activities by State and Type of Funding

CDC funds asthma activities in 36 states and in the District of Columbia.

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More Health Departments Funded to Developand Implement Asthma Control Programs In2001, CDC provided funds to 13 additional statehealth departments plus the Washington, D.C.,Health Department to develop or implementasthma control programs. This brings to 26 thenumber of health departments now receivingfunds to plan programs that will havesurveillance, intervention, and partnershipcomponents. The 25 states funded for asthmacontrol programs are California, Colorado,Connecticut, Georgia, Idaho, Illinois, Iowa, Maine,Maryland, Michigan, Minnesota, Missouri,Nebraska, New Hampshire, New Jersey, NewMexico, New York, Oregon, Rhode Island, Texas,Utah, Vermont, Virginia, West Virginia, and Wisconsin.

Funds Provided to Implement AsthmaInterventions Within the past year, CDC fundedeight sites to implement one of two provenasthma interventions (Asthma Care Training forKids and Open Airways for Schools). Thepurposes of these funds are to decrease hospitaland acute care visits and to increase compliancewith asthma care and medication plans. The eightsites are Chula Vista Elementary School District(California); Bronx-Lebanon Hospital Center(New York); the American Lung Association ofMetropolitan Chicago; the American LungAssociation of Colorado; the PhiladelphiaDepartment of Health; Harris County HospitalDistrict (Texas); Babyland Family Services,Inc. (New Jersey); and the Asthma andAllergy Foundation of America (WashingtonState chapter).

CDC Organizes a Public Health Response toAsthma CDC and the Public Health TrainingNetwork conducted live interactive satellitebroadcast training, “A Public Health Response toAsthma,” on May 17, 2001. More than 1,000people received continuing education credit forthe broadcast, which provided an overview of thedisease and demonstrated sound approaches forconducting asthma surveillance, buildingstatewide coalitions, and implementinginterventions in schools. Several state healthdepartments used the broadcast as a kickoff event for their scheduled asthma coalition meetings.

Funds Provided to Seven Grantees forControlling Asthma in American Cities ProjectCDC provided funds to seven grantees to useinnovative collaborative approaches to improveoverall asthma management among urbanchildren and adolescents up to 18 years of age.The grantees are the St. Louis Regional AsthmaConsortium, Children’s Hospital of Philadelphia,the American Lung Association of Minnesota, theUniversity of Illinois, Columbia University (NewYork), the Central Virginia Asthma Consortium,and the University of California. The desiredoutcome of this project is a decrease inasthma-related morbidity.

Asthma Case Tracking Under Way To providebetter estimates of asthma incidence, CDC isfunding the Kaiser Foundation Research Institute(Portland, Oregon) and the Miami-Dade CountyHealth Department (Miami, Florida) to develop

A c c o m p l i s h m e n t s

models for identifying new asthma cases. Thisproject will define a network of providers withineach population base and determine the healthcare utilization practices of people with asthmawho visit those providers. This project will alsofacilitate the identification of population-basedfactors that are associated with the developmentof asthma.

CDC and Malaysian Researchers AnalyzeForest Fire Health Effects In 2001, CDCcontinued working with the Malaysian Ministry ofHealth to analyze data gathered in conjunctionwith forest fires that occurred in that country in1997. Malaysian researchers came to Atlanta andworked with CDC epidemiologists to prepare thedata and to start the preliminary analysis. CDCepidemiologists traveled to Malaysia andconducted workshops focused on improving thequality of hospital discharge data collected there.This study will provide a better understanding ofthe health effects that occur from exposure to airpollutants caused by forest fires.

Biomonitoring

National Report on Human Exposure to Environmental Chemicals

CDC Launches First National Report onHuman Exposure to EnvironmentalChemicals In March 2001, CDC released

this major scientific examination of the U.S.population’s exposure to 27 environmental

chemicals—24 of them for the first time inhistory. CDC scientists looked at levels of all 27chemicals in people who participated in the 1999National Health and Nutrition ExaminationSurvey (NHANES). NHANES is a series of surveysthat CDC conducts which collect data on thehealth and nutritional status of the civilian,noninstitutionalized U.S. population. The Reportprovides information about exposure to important environmental chemicals, includingmetals such as lead and mercury;organophosphate pesticides; phthalates; andcotinine, a marker for exposure to tobaccosmoke. In addition to levels of three chemicals—lead, cadmium, and cotinine—that had beenmeasured in other surveys, the laboratorydetermined reference ranges for 24 environmentalchemicals from a nationally representative groupof people not known to have any specificexposure to the chemicals beyond thatexperienced in the general population. Thesereference ranges will be extremely helpful topublic health officials, physicians, and healthresearchers because levels above these rangesusually indicate exposure worthy of furtherinvestigation. The overall purpose of the Report isto provide unique exposure information to publichealth officials, scientists, and physicians to helpprevent disease that results from exposure toenvironmental chemicals.


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Methods

New Methods Strengthen BiomonitoringCapacity During fiscal year 2001, CDC laboratoryscientists developed several new methods formeasuring low levels of environmental chemicalsin people. These methods, which are essential tostudying the relation between exposure levelsand adverse health effects, will help public healthofficials, physicians, and researchers learn more about what chemicals are getting into people’s bodies. Hazardous substances that can be better measured in blood and urine using these new methods include the following:

• Polyaromatic compounds, many of which are known to be carcinogenic. CDC currently is analyzing the blood and urine specimens of firefighters who responded to the World Trade Center (WTC) attack to determine whether they were exposed to these chemicals.

• Phthalates, which are chemicals that have the potential to be hormonally active and are found in soap, shampoo, hair spray, nail polish,and durable and flexible plastic products. Phthalates given at very high doses to pregnant animals have caused birth defects among offspring.

• The endocrine disruptor bisphenol A, which isused in dental sealants.

• Nonpersistent pesticides.• Nicotine, nicotine

metabolites, free nicotine, and menthol from tobacco products. The method for measuring menthol is particularly noteworthy, given that African Americans who smoke mentholated cigarettes mayhave an increased risk for smoking-related disease.

• Trihalomethanes, which are water-disinfection by-products associated with an increased risk for bladder cancer and birth defects. CDC laboratory scientists can now measure eight times as many samples at one time as they were able to measure using previous methods.


Using improved methods, CDC scientists can measure 31 different volatile organic compounds in people’s blood.

Separating arsenic into its various types (species) allows scientists to measureboth dietary and environmental exposures to this toxic chemical.

• Mercury, uranium, thorium, and both total and speciated arsenic.

• Selenium, an element essential to human health but toxic at high levels.

• Plutonium, a deadly radioactive element.• Volatile organic compounds (VOCs), some of

which are associated with cancer and neurological dysfunction. CDC developed an improved method for measuring 31 different VOCs in human blood. By improving methodsof sample handling, analysis, and data reduction, environmental health scientists cannow measure 10 times as many samples at one time as they could only 2 years ago. Such strides enabled CDC to rapidly address questions about exposure to VOCs among firefighters who participated in WTC rescue efforts.

CDC Calls for Renewed Interest in Children'sExposure to Environmental ChemicalsMonitoring levels of environmental chemicals inchildren presents several difficulties. Amongthese are the small sample volumes that can beobtained from children, the invasive nature of thesampling, and the Institutional Review Boardconcerns. At the American Chemical Society'snational meeting, CDC chaired a sessionaddressing these difficulties and thencontributed to and edited a special issue of theJournal of Exposure Analysis and EnvironmentalEpidemiology devoted to assessing children's

exposures to hazardous environmentalchemicals. This special issue (J Expo Anal EnvironEpidemiol 2000;10[6 Pt.2]:611–29) contains sevenarticles by CDC authors. One article is anoverview of the challenges and complexitiesresearchers face in assessing children's exposureto environmental chemicals. The other articlesaddress sample collection, measurements ofchemicals in various media (including umbilicalcord blood, serum, and urine), and techniquesand methods for measuring certain chemicalssuch as phytoestrogens and pesticidemetabolites. Laboratory scientists and publichealth officials will find this information useful asthey work to find the best ways to handlescientific and policy matters related tobiomonitoring in children.

Methanol Identified as Contaminant in ElSalvador Poisoning During late spring 2001, arash of poisonings from methanol-contaminatedliquor in El Salvador left 120 people dead. Inresponse to this massive exposure, CDC'senvironmental health laboratory developedmethods for identifying methanol, ethanol, andrelevant metabolites in human blood. CDC dataconfirmed that methanol contamination was thelikely cause of this poisoning epidemic. Thesedata assisted local public health officials inminimizing additional poisonings fromcontaminated liquor.


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The Role of Biomonitoring in Public HealthInvestigations

Urine Analyzed for Heavy Metals AfterNational Monument Forest Fire In May 2000, acontrolled fire at Bandelier National Monumentunexpectedly got out of control, burning muchof the monument and parts of the Los AlamosNational Laboratory. Authorities evacuated25,000 people to reduce their exposure to theforest fire smoke and possible exposure toradioactive releases from the laboratory. Althoughtesting of urine for environmental chemicalsrevealed elevated levels of nickel, CDC investigators

determined that the nickel was not released fromthe laboratory and that the health of the evacuatedpopulation was not compromised.

Levels of Fetal Exposure to OrganophosphatePesticides Measured Working with academicinstitutions from several regions of the country,CDC laboratory scientists measured levels oforganophosphate pesticides in the cord bloodand postpartum meconium of infants. Theseinfants are being studied to determine therelation between adverse neurobehavioraleffects and exposure to environmental chemicals,particularly to these pesticides. Although thestudies are still in progress, preliminary results


After a fire burned much of Bandelier National Monument and parts of Los Alamos National Laboratory, CDC tested the urine of people who were evacuated to determine whether these people had beenexposed to hazardous substances from the fire.

indicate that the pesticides generally passthrough the placenta and thus expose the fetusto these pesticides, which are neurotoxicants.

Proximity to Agricultural Fields Is NotSignificantly Associated with Overall PesticideLevels in Urine In 2001, CDC completed aninvestigation of exposure of children topesticides in Yuma County, Arizona. The purposeof this cross-sectional study was to determinewhether children who lived or attended school inthe vicinity of agricultural fields were exposed togreater amounts of pesticides than were childrenwho lived or attended school further fromagricultural fields. From October 1999 to February2000, CDC collected urine and dust samples; atotal of 152 households and six schoolsparticipated. Urine samples were tested fororganophosphate pesticide metabolites, anddust samples were tested for 43 specificpesticides. Levels of pesticide metabolites inurine and levels of pesticides in dust were low.There was no association between the summaryvariable of all pesticide metabolites in urine anddistance from agricultural fields. However, therewas an association between distance andsome of the individual pesticide metabolitesin the urine.

Building State Capacity in Biomonitoring

Funding Awarded to States In 2001, CDCawarded 25 planning grants totaling $5 million to33 states to develop, implement, and expand

state-based biomonitoring programs to helpprevent disease from exposure to toxicsubstances. Individual states, as well as consortiacomprising several states, received funding.Grants are designed to help states strengthentheir public health infrastructure. States will alsobe able to plan how they will track exposuretrends and assess effectiveness of efforts toreduce exposure to toxic substances. Finally,states will be able to increase their capacity tomeasure many toxic substances in people,including such vulnerable groups as children, theelderly, and women of childbearing age.

Public Health EmergencyResponse

Unannounced Bioterrorism ExerciseHeld A full field exercise developed andmanaged by CDC called “Exercise

Hanuman Redux 2001” (HR 2001) was heldduring 2 days in August 2001 in Louisville,Kentucky. It was one of a very few “no-notice” (unannounced), 24/7, player-driven exercises everheld in the United States. From the localperspective, the August exercise evaluated thecommunity’s ability to execute its emergencyoperations plan, policies, and procedures and use its systems and facilities to deal with abioterrorism event. In response to the exercisescenario, CDC rapidly field-deployed two


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A CDC scientist and a local health educator use aglobal positioning system to plot sample extractionlocations for investigating children’s exposure to pesticides in Yuma County, Arizona.

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emergency response coordinators and 10epidemiologists to investigate the event. HR 2001marked the first time the National PharmaceuticalStockpile Program had field-deployed its assets.The lessons learned from HR 2001 provedinvaluable in responding to the World TradeCenter and Pentagon events less than 1 month later.

Emergency Response Efforts Put into Actionon September 11 During the past several years,CDC has responded to a variety of natural andtechnologic disasters, each of which hadsignificant public health consequences. CDC also participated in chemical, radiological, andbiological terrorism exercises. These activitiesproved invaluable in preparing CDC emergency

response personnel to rapidly and effectivelyrespond to the event that began September 11.CDC’s Emergency Operations Center wasfunctioning within minutes of the World TradeCenter and Pentagon attacks, maintaining 24/7coverage through mid-December. CDC alsodeployed hundreds of specialists to New York City to conduct on-site activities. These activities included serving as a liaison with other federalagencies and the New York state and city healthdepartments in areas such as worker protectionand environmental sampling and helping identifyand quantify respiratory, eye, and other risks toworkers at Ground Zero. Additionally, CDCrecently used funds received from the FederalEmergency Management Agency to award two


Hundreds of CDC specialists were deployed toNew York City to conduct activities such as bio-chemical monitoring at Ground Zero.

A CDC staffer works at the on-site Emergency Operations Center for Exercise Hanuman Redux 2001, a no-notice bioterrorism response exerciseheld in Kentucky in August 2001.

grants: $4.8 million to the New York City firedepartment and $2.4 million to the New YorkState Department of Health to conductbiomedical monitoring for responders at Ground Zero.

Nearly 3.75 Million Antibiotic TabletsDelivered to Treat Anthrax CDC’s NationalPharmaceutical Stockpile (NPS) EmergencyOperations Center was still fully functioning withstaff on 24-hour alert after the September 11attacks when CDC responded to the first case ofanthrax in Florida. At the request of state andlocal officials, CDC, through the NPS Program,arranged for the transportation of a CDCepidemiologist and the NPS Program’s TechnicalAdvisory Response Unit to Florida and NorthCarolina to investigate and respond to anthraxexposures. CDC also transported specimens and aCDC epidemiologist to a specialty lab in Flagstaff,Arizona. From October 15 to November 29, CDCdelivered nearly 3.75 million tablets of threedifferent antibiotics (amoxicillin, ciprofloxacin,and doxycycline) for postexposure preventivetreatment of postal workers, mail handlers, postalpatrons, and other employees in affectedbuildings. CDC accomplished this feat inresponse to 65 separate requests from 10different states and the District of Columbia.CDC’s average response time from request todelivery was 5 hours.

CDC and New York City Department of HealthCollaborate on Post-September 11 HealthAssessment The New York City Department ofHealth (NYCDOH) and CDC collaborated on anassessment of health effects and needs amongresidents of Lower Manhattan affected by theevacuation and environmental contaminationcaused by the attack on the World Trade Center.Staff from NYCDOH and CDC developed aquestionnaire to obtain information fromresidents concerning (1) demographics, (2) accessto utilities and health services, (3) mental andphysical health status, and (4) urgent needs andconcerns. The survey instrument included a 17-item screening test for symptoms of posttraumaticstress disorder validated for a U.S. population.Survey teams comprising CDC and NYCDOH staffmembers received training on how to administerthe questionnaire and respond to intervieweeconcerns. From October 25 through November 1,2001, these teams conducted 414 interviews ofstatistically representative, randomly selectedhouseholds from three well-defined communitiesin Lower Manhattan. Within 1 week of datacollection, CDC provided NYCDOH with a reportthat included recommendations for public healthinterventions. On the basis of the results of thisassessment, NYCDOH developed a plan tofacilitate communication, mitigate the effects ofpoor air quality, and address mental healthconcerns in these neighborhoods.


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Specialized containers designed to fit into wide-bodied aircraft enabled thousands of pounds of antibiotics, medical supplies, and protectiveequipment to be shipped through the NationalPharmaceutical Stockpile Program to rapidlyrespond to the September 11 and anthrax attacks.

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Terrorism Response Planning Guidance Put onthe Web The planning guidance for biologicaland chemical terrorism response recently Web-posted by CDC is designed to help state and localpublic health officials determine the roles of theirdepartments in responding to biological andchemical terrorism and to understand how publichealth response activities fit within the overall federal, state, and local emergency management system. This guidance can also be used to helphealth departments coordinate their efforts withthe many agencies and organizations at all levelsof government that ultimately would respond toa biological or chemical terrorism event. The 106-page guidance document is available on CDC’s

Web site at http://www.bt.cdc.gov/documents/planning/planningguidance.pdf.

Training Video Created for State and LocalHealth Departments The ability of public healthand emergency management officials to providea coordinated response at the local level hasmade, and will always make, a tremendousdifference in minimizing injury, illness, and deathin an emergency situation. This new NationalPharmaceutical Stockpile video will provide CDCstaff with an opportunity to train thousands ofindividuals across the country quickly andinexpensively, helping to ensure rapidprocurement, transport, and staging of CDC


The New York City Department of Health collaborated with CDC to develop a plan to facilitate communication, mitigate effects of poor air quality, and address mental health concerns in neighborhoodsaffected by the World Trade Center attack.

assets in an emergency situation. The videoformat is particularly important because pushpackage sites are at undisclosed locations andcannot be toured. (A push package is a portable,fully stocked repository of drugs, antidotes, andmedical/surgical supplies designed to resupplystate and local public health agencies within 12hours of a terrorism incident.) For most publichealth and emergency management planningofficials, this video will provide the onlyopportunity for them to view a push package.

Applied Research Leads to ProgramInnovations In 2001, CDC conducted appliedresearch that led to program innovations inseveral areas, such as the development of adultand pediatric dosing guidelines. Working with aninteragency panel of medical and pharmaceuticalexperts and industry representatives, CDCoutlined the specific dosing requirements foradults and children in an emergency setting and incorporated these guidelines into drug information sheets for patients. In addition, in2001, CDC scientists wrote two articles that werepublished in major pharmaceutical journals. Thefirst article presented an overview of CDC’sNational Pharmaceutical Stockpile Program andthe second provided technical advice forpharmacists involved in terrorism planning.

Drug Information Provided in More than 40Languages The mass postexposure preventivemedication needed by thousands, possiblymillions, of people under chaotic conditionsfollowing a bioterrorism event may putuncommon stress on routine medical practice

associated with dispensing medications,including providing dosing instructions and druginformation to patients. It may be particularlyproblematic to provide this type of informationto people who best understand a language otherthan English and who would benefit from dosinginstructions and drug information in their nativelanguage. Consequently, CDC developed dosinginstruction labels and drug information sheets forciprofloxacin, doxycycline, amoxicillin, andpenicillin in more than 40 languages. The druginformation sheets will provide a clear andunderstandable reference for patients about howmany tablets to take, when to take them, whatprecautions to watch for, and what side effects toexpect. CDC distributed CDs containing easilyviewable files of the multilingual druginformation sheets and dosing instruction labelsto all state and local health departments inJanuary 2002.

More Staff Trained on InternationalEmergency Response CDC has enlarged itsreservoir of staff members capable of respondingto requests for CDC assistance in internationalemergencies. In 2001, 12 CDC staff memberscompleted the 2-year International EmergencyCapacity Development (IECD) training program.The program provides trainees with languageinstruction, teaching seminars on technicaltopics, and supervised international fieldexperience. Many past graduates of the IECDprogram have increased their internationalresponsibilities in their current jobs, therebyenhancing the ability of CDC to respond toglobal health threats. For example, the Division of


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Reproductive Health has in the past few yearsprovided the first epidemiologic assessments ofthe burden of reproductive health-relatedmorbidity and mortality in several refugee campsworldwide. These activities were initiated and ledby members of the first and second IECD classes,which graduated in 1997 and 1999.

Palau Center for Emergency HealthEstablished As part of the Pacific EmergencyHealth Initiative, CDC staff traveled to Palau inSeptember 2001 to launch the Palau Center forEmergency Health (PCEH), the first Pacificregional training center for emergency publichealth and medical facilities. PCEH is a CDCventure developed in partnership with theRepublic of Palau and the Palau CommunityCollege. In addition to opening the center, CDCrepresentatives conducted two training sessionsfor 11 Pacific Island nations participating in PCEH.The first course, the Emergency Public HealthPlanning Workshop, introduced the participantsto the fundamental concepts of emergencypreparedness as applied to the public health andmedical effects of natural and technologicaldisasters. Each of the participating jurisdictionsended the 40-hour course by developing publichealth emergency operations plans. The secondcourse, the Emergency Medical ServicesWorkshop, provided 80 hours of hands-onemergency medical services training to firstresponders.

Childhood Lead PoisoningPrevention

Lead Screening Plans Submitted to CDCAn important element of a comprehensiveprogram to eliminate childhood lead

poisoning is an effective lead screening strategy.The goal of lead screening is to identify childrenwho need individual interventions to reducetheir blood lead levels. CDC is committed toeliminating childhood lead poisoning by 2010.Because childhood lead poisoning no longer isconsidered to be a broad, society-wide problembut rather one that exists in particular at-riskpopulations, CDC refocused its interventionefforts and has been conducting high-intensitytargeted screening in specific communities.When this crucial effort has been completed, the


The first class to graduate from the Palau Center for Emergency Health (PCEH). PCEH,opened by CDC in 2001, trains citizens of 11 participating Pacific Island nations onfundamental concepts of emergency preparedness and emergency medical services.

path will be paved for the implementation ofeffective and successful interventions. In 2001, alllead grantees developed and submitted theirscreening plans to CDC. These plans are currentlyundergoing review.

Regional Lead Conferences Generate GreatInterest Eight regional lead conferences(Pittsburgh, Pennsylvania; Portland, Maine;Asheville, North Carolina; Indianapolis, Indiana;Austin, Texas; Des Moines, Iowa; Salt Lake City,Utah; and Oakland, California) were held during2001 to give state and municipal Childhood LeadPoisoning Prevention Program (CLPPP) granteesand CDC the opportunity to participate in formaland informal dialogue and to exchangeinformation about critical program issues. Theseconferences helped build and strengthenregional networks and increased participants'knowledge about data management andchildhood lead poisoning prevention. Theseconferences also created a forum for states andlocal CLPPPs to develop strategies and innovativeapproaches to improve the overall impact ofchildhood lead poisoning prevention programs.Attendance was greater at the regionalconferences than at previous annual nationalconferences.

Strategic Partnership Promotes National LeadPoisoning Prevention Week CDC collaboratedwith the U.S. Environmental Protection Agencyand the U.S. Department of Housing and UrbanDevelopment to commemorate the first-everNational Lead Poisoning Prevention Week, whichwas observed the week of October 21, 2001. A

major outcome of this partnership was thedevelopment of a Lead Poisoning PreventionMedia Outreach Kit for state and local healthdepartments. The toolkit is intended to facilitaterelationships with local and state mediarepresentatives and to increase awareness aboutchildhood lead poisoning.

CDC Lead Poisoning Prevention Web SiteRedesigned The content, design, and navigationof CDC's Web site on lead poisoning preventionhas been updated and upgraded. The revisedWeb site is intended to better serve the publicand national program needs for childhood leadpoisoning prevention information and resources.To access the site, go to http://www.cdc.gov/nceh/lead/lead.htm.

Diversity/Disparities

Mold Growth Investigated in Homeson Turtle Mountain IndianReservation CDC conducted an

investigation of mold growth in residentialdwellings and of the potential health effects ofexposure to mold among residents on the TurtleMountain Indian Reservation in North Dakota.The investigation included three phases:environmental assessment of dwellings, humanhealth survey, and environmental sampling.Environmental and human health data werecollected on a stratified, weighted, randomizedsample of reservation homes. A total of 137homes were initially surveyed by CDC


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environmental assessment teams. A highprevalence of mold growth was identified inmore than 60% of the homes surveyed duringthe visual inspection. In addition, a number ofcritical public health threats were discovered,including several electrical system hazards; twogas leaks; several sewage/sump pump leaks;several pest infestations; and in one home, thepotential for carbon monoxide poisoning. Thisproject will help researchers understandenvironmental factors associated with moldgrowth, knowledge that in turn will help improveproblem housing and that may help eliminateenvironments that allow molds to thrive.

Native American Tribes Receive RadiationDose Estimates CDC provided Northwest NativeAmerican tribes with radiation dose estimates forrepresentative individuals who were exposed to radioactive iodine released from the HanfordNuclear Reservation in Washington State. Thesedose estimates will help members of eightseparate Native American tribes and nationsdetermine how historic releases of radioactiveiodine from Hanford may have affected theirhealth. These dose estimates are based onspecific Native American lifestyle and dietarypractices that individual tribes reported.

Environmental Health Services

Chemical Weapons Disposal

P rogress Continues in Disposing ofStockpiled Chemical Weapons CDCcontinues to maintain a strategic

partnership with the Department of Defenseinvolving funding in excess of $1 million tosupport CDC’s oversight of the safe disposal ofthe nation’s chemical weapons. This partnershipenables CDC to effectively protect the health ofthe almost one million people working or livingnear chemical weapons stockpile sites. SinceSeptember 2001, more than 14.9 million pounds


A home on the Turtle Mountain Indian Reservation in North Dakota shows damagecaused by the wet environmental conditions in the community. The high moisturelevels both indoors and outside are likely the main contributor to CDC's finding that60% of the homes inspected had visible mold contamination.

of chemical agents and weapons have beensafely destroyed. CDC will continue to keep itspromise of protecting the public’s health whilemanaging the safe disposal of the remaining 48million pounds of chemical agents and weapons.

Nerve Agent Munitions Found Near Children’sNature Trail Safely Destroyed CDC providedpublic health and safety oversight in the safedestruction of six “bomblets” found at a landfill atRocky Mountain Arsenal, Colorado, in closeproximity to a children’s nature trail. Eachbomblet is only about the size of a grapefruit buthas enormous deadly potential. Together thesesix bomblets contained a total of eight poundsof sarin nerve agent, enough to kill more than77,000 people. The bomblets originally weredesigned for a 1950s-era missile but had neverbeen used. CDC partnered with the U.S. Armyand the state of Colorado to identify a safetechnology and process for disposal of thebomblets, which were successfully destroyedwith no potential health threat to the nearbycommunity. The disposal process will serve as amodel for destruction of any chemical munitionsfound in the future. Rocky Mountain Arsenal wasformerly used by the U.S. Army to manufacturechemical weapons and was later leased byindustry to produce agricultural pesticides. Thefacility is located about 10 miles northeast ofdowntown Denver, Colorado.

Limits Published for Exposure to Nerve AgentCDC finalized and published its recommendationsfor protective exposure limits to chemical nerveagents during disposal. CDC’s recommendations

are based on information obtained from ascientific workgroup of nationally recognizedscientists and medical professionals. Therecommended limits, which were published inthe Federal Register for public comment, willensure that workers and nearby communities areprotected from adverse health effects caused bynerve agent exposure.

Open Forum Held on Exposure Limits forBlister Agent During September 10–11, 2001,CDC convened a panel of national scientificexperts and medical professionals in an openforum to review and discuss exposure limits forsulfur mustard agent at chemical agent disposalfacilities. Currently, seven national chemicalstockpile sites in the United States are storingsulfur mustard agent that must be safelydisposed of under congressional mandate. Thepanel's scientific findings have been analyzed byCDC and will be used to prepare CDC's finalrecommendations on exposure limits for sulfurmustard. CDC's recommendations will be bothconservative and protective of the health of themore than 900,000 workers and residents in thenearby communities. The exposure limits will bepublished in the Federal Register to provide anopportunity for public review and comment.

Independent Investigation of OregonChemical Weapons Storage Site EasesConcerns The Oregon State Health Departmentand Department of Environmental Quality askedCDC to conduct an independent review of thecurrent monitoring strategy and program at theUmatilla Chemical Depot (UMCD). UMCD is one


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CDC provided oversight in the safe destruction ofnerve agent munitions (shown here) found close to a children’s nature trail in Colorado.

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of eight continental U.S. chemical weaponsstockpile sites. Prior to destruction of chemicalweapons, the U.S. Army is required to monitorthem to verify that there are no leaks posing ahealth risk to the workers or the community. CDCconducted a thorough technical evaluation ofthe chemical agent monitoring program put inplace by the U.S. Army at UMCD. Overall, themonitoring strategy was deemed to beprotective of public health. CDC did providesome recommendations for improvement, whichwere implemented by the U.S. Army.

New Chemical Agent Monitoring ConceptsExplored CDC met with Oregon state officialsand U.S. Army officials to review innovativemonitoring technologies that are able to detectmore than one type of chemical agent at thesame time. Simultaneous detection of more thanone chemical agent is helpful at a chemical agentdisposal facility that must destroy multipleagents. CDC formulated a preliminary monitoringstrategy that makes recommendations from theperspective of public and worker healthprotection.

CDC Meets with Concerned Citizens One way inwhich CDC fulfills its role of oversight of eightchemical weapons stockpile sites is to meet withpotentially affected local citizens to address theirconcerns. Currently, only one stockpile site isdestroying chemical agents in the continentalUnited States. Two other sites are scheduled tobegin disposal operations within the next year. Asthese facilities near completion, members of thepublic are requesting more independent public

health information. In response to their requests,CDC has visited the disposal sites and met withcommunity members to address their concernsabout chemical weapons disposal near theirhomes.

Capacity-Building Activities

Strategy Implemented for RevivingEnvironmental Health Services System CDCfollowed a rigorous schedule in producing astrategy to revitalize the environmental healthservices system in the United States. Althoughmany major accomplishments have been madein the environmental health services field, overtime the resources and capacity of public healthagencies to deliver environmental health serviceshave steadily declined. The initial draft of thestrategy was developed in 3 months with theparticipation of an internal steering committeeand a 31-member external partners workinggroup representing the environmental healthand protection practice community; specialpopulations; academia; advocacy groups; andrepresentatives from the Agency for ToxicSubstances and Disease Registry as well as otherCDC centers, institute, and offices. The draft plan,which is viewed as a working document, hasbeen reviewed by more than 100 additionalenvironmental health and public health expertsand advocacy organizations. CDC madesignificant progress toward revitalization in 2001by awarding millions of dollars to state and localhealth departments and universities to buildpublic health capacity and improveenvironmental health services. The next step is to


finish identifying needed resources, organizingand implementing activities described in thestrategic plan, and creating a time line foraccomplishing the objectives.

CDC Awards $3 Million in CooperativeAgreements to Boost Environmental HealthServices As part of its plan to revitalize thenation’s environmental health services system,CDC awarded $1.5 million in cooperativeagreement grants to three state and four localhealth departments. The grants cover severaldifferent projects or focus areas, such as buildingenvironmental health capacity in state and localhealth departments and controlling rodents andimproving unhealthy home environments inPhiladelphia and New York City. CDC alsoawarded $1 million in cooperative agreementgrants to four universities to support a programcalled “Building Communities of Excellence inEnvironmental Health.” This program usesschools of public health to assist state and localhealth departments in developing state-of-the-art environmental health programs. Additionally,CDC awarded $500,000 to four other universitiesto improve the ability of environmental healthprograms and practitioners to provideenvironmental health services nationwide. These cooperative agreement funds will enablethe universities to determine which proceduresare effective for conducting environmentalassessments at public events, to develop training modules on essential environmentalhealth services, and to craft training modules for practitioners new to the field ofenvironmental health.

Environmental Health Specialist NetworkExpanded In fiscal year 2001, CDC awarded$700,000 to seven additional states to implementthe Environmental Health Specialist Network(EHS-Net). EHS-Net was created to facilitate theexchange of information and ideas betweenepidemiologists and environmental healthspecialists. EHS-Net is based on the existinginfrastructure of FoodNet, which is a Web-basedcommunications tool that addresses the needs offood professionals in various occupations. EHS-Net is designed to (1) enable understanding of the environmental causes of foodborne illness;(2) strengthen the relationships amongepidemiologists, environmental specialists, andlaboratory staff at the state and local levels; and(3) identify and offer training opportunities forenvironmental health specialists. Currently, anEHS-Net partnership exists among CDC, the Foodand Drug Administration, and eight states(California, Colorado, Connecticut, Georgia, NewYork, Minnesota, Oregon, and Tennessee). An EHS-Net environmental assessment tool isundergoing pilot testing.

Workshops on Drinking Water SystemsConducted Up to half of the population of somestates in this country drink water from smallsystems not regulated by the Safe Drinking WaterAct. The quality of the drinking water from thesesystems is generally unknown and may besuspect. For these reasons, CDC convened twoworkshops to allow state and local practitionersto present their perspectives, discuss publichealth problems, and explore avenues forresolving issues pertaining to small, nonfederally


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In 2001, CDC made significant progress toward revitalizing the environmental health services system in the United States.

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regulated drinking water systems. Three broadareas of common concern were identified: (1)state and local resources are inadequate foraddressing issues related to small systems, (2)members of the general public being served bythese small systems are often overconfident orcomplacent about their drinking water quality,and (3) states need technical assistance andguidance in developing and maintaining thesesystems. CDC is working with state and localrepresentatives to prepare a joint reportdescribing the issues and potential strategies toaddress the concerns.

Cause of Wyoming Waterborne OutbreakIdentified In conjunction with the WyomingDepartment of Health and several other stateand federal agencies, CDC coordinated aninvestigation of environmental risk factors andsystem failures potentially associated with acutegastroenteritis among people who had recentlybeen on a snowmobiling vacation in the Big HornMountains. Environmental assessmentsconducted in three area lodges included foodservice operations, water supply systems, andsewage disposal. To determine risk factorsassociated with the illness, a retrospective cohortstudy was conducted among people identifiedfrom guest registers. Stool and water systemsamples were collected for laboratory analysis.Statistical analysis from the retrospective cohortstudy suggested that the illness was associatedwith water consumption and that risk of illnessincreased significantly with the number ofglasses of water consumed. Laboratory resultswere positive for Norwalk-like virus, genotype II.

The environmental assessment of the propertyrevealed that an inadequately installed sewagesystem was delivering effluent into shallow soilthat had poor filtering capacity. This effluentlikely reached the underground sources of thefacility's water supply. The resulting illness eventrepresented the largest waterborne outbreakever reported in Wyoming. The success of thisinvestigation demonstrated the advantages ofcoordinating environmental public healthpractice with traditional epidemiologic andlaboratory practices.

Cruise Vessel Sanitation

“No-Sail Order” Issued A cruise vessel with 224passengers and a crew of 100 received a “no-sailorder” from CDC because the vessel was criticallydeficient in storing food at proper temperatures,cleaning and sanitizing dishware, and providingproperly chlorinated potable water. CDCmaintained close inspection of the vessel toensure that all deficiencies were corrected beforeallowing the ship to sail. CDC has conductedapproximately 550 of these inspections since1999. This was only the second no-sail order to have been issued during that time period.

CDC Ensures Healthy Conditions on CruiseShips The Vessel Sanitation Program OperationsManual 2000, published by CDC in November2000, allowed cruise lines to transition tocompliance with new requirements during 2001.During the transition period, cruise lines were toimplement provisions of the 1999 Food and Drug


Administration Model Food Code required by thenew manual. CDC conducted a series of trainingsessions on the new requirements, followed byunannounced operational inspections of thevessels to ensure implementation andcompliance. Procedures and instructions on howto design and build potable water systems andfood-handling areas for cruise vessels wererevised and published by CDC in Guidelines forthe Sanitary Construction of Cruise Vessels Destinedto Call on U.S. Ports, August 2001. This manual hasbecome the international standard for sanitaryconstruction of cruise vessels.

Illnesses Aboard Ship Can Now Be Reportedby E-Mail At-sea cruise vessels can nowelectronically file mandatory reports of illnessdirectly to a CDC database using theGastrointestinal Illness Surveillance System, an E-mail–based reporting system. Data submitted byvessels are electronically reviewed, and ifthreshold levels for illness are reached, thesystem automatically notifies CDC personnel forfollow up.

Environmental Health TrackingNetwork

Workgroups Provide Input onImplementing CDC/ATSDRProposed Plan for an

Environmental Public Health TrackingNetwork In January 2001, the Pew EnvironmentalHealth Commission issued the report America’sEnvironmental Health Gap: Why This Country Needsa Nationwide Health Tracking Network. By August 2001, CDC and the Agency for Toxic Substances and Disease Registry (ATSDR) staff developed aplan for such a network entitled CDC and ATSDR’sProposed Plan for an Environmental Public HealthTracking Network. The two agencies thenassembled 60 scientists, managers, and policyspecialists to serve on workgroups to addresspertinent tracking issues. Workgroup membersrepresent CDC and ATSDR, the U.S. EnvironmentalProtection Agency (EPA), the Department ofHousing and Urban Development, academia,advocacy groups, professional organizations, andstate and local public health and environmentagencies and the national organizations thatrepresent these agencies.


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CDC and ATSDR have begun developing practicalrecommendations for implementing theproposed plan. These workgroups and the issuesthey will address are as follows:

• Organization and management to (1) define roles and establish collaborative linkages among state and local public health and environmental agencies and among CDC/ATSDR, EPA, and other partners and (2) identify state and local capacity needed to implement the tracking network

• Data technology and tracking methodology to (1) identify relevant nationaldata standards, (2) establish system specifications, and (3) describe potential prototypes or models for automating, linking, and analyzing hazard, exposure, and health-outcome data

• Tracking system inventory and needs assessment to (1) identify and describe existing tracking systems at the national, state, and local levels, (2) determine priorities for integrating existing tracking systems, and (3) identify and prioritize the development of new systems

• Translation, policy, and public health action to define state, local, and federal actions that can ensure a rapid and effective response to data and other information

generated by the environmental public health tracking network (e.g., implementing disease prevention strategies and initiatingprevention research)

To date, CDC and ATSDR have cosponsored akickoff meeting in Atlanta for workgroup members.In addition, one workgroup already has craftedrecommendations for the plan’s implementation.


CDC and ATSDR have developed a model in their proposed plan for an environmental public healthtracking network.

Genomics

New Centers for Genomics and HealthEstablished In 2001, CDC awardedfunding to three schools of public

health, establishing the first Centers for Genomicsand Public Health. The University of Michigan, theUniversity of North Carolina, and the University ofWashington will each receive approximately$300,000 per year for 3 years. Through acooperative agreement between the Associationof Schools of Public Health and CDC, each centerwill develop a regional hub of expertise to useinformation about gene-environment interactionsassociated with disease to develop new strategiesfor improving health. The centers will build onand complement existing programs at theuniversities (in public health, medicine, genetics,and other disciplines) and will establish relationshipswith local and state health departments.

Centers may also draw on other regionalresources, such as professional organizations, theclinical community, and industry, to developactivities in three areas: contributing to theknowledge base on genomics and public health;providing technical assistance to local, state, andregional public health organizations; anddeveloping and providing training for the currentand future public health work force. Althoughsome of these activities now exist at schools ofpublic health, the prevailing thought is that establishing the centers will generate a high level

of synergy, collaboration, and networking amongschools of public health and other public healthinstitutions. With this collaborative approach, CDChopes to draw attention to gaps in translating genediscoveries into disease prevention and todemonstrate, through examples, a way to beginaddressing the gaps.

Genomics Toolkit Project Initiated Buildingcapacity in genomics in state public healthagencies requires tools that are useful inachieving the aims of health promotion anddisease prevention. Success also depends upon asufficient level of commitment from public healthagencies to use these tools in public healthprograms. To help make these tools readilyavailable and to encourage the commitment touse them, CDC is developing a Genomics Toolkitfor state and local public health agencies. Thetoolkit will be the product of a working groupcoordinated and convened by the Association ofState and Territorial Health Officials (ASTHO) thatincludes representatives from CDC and otherpublic health organizations with interests inlaboratory science, chronic disease, public policy,genetics, maternal and child health, local publichealth, and epidemiology. The project is alsobeing guided by the results of ongoing needsassessments of state and local public healthagencies. The Genomics Toolkit is intended to bean evolving document that will be updated asnew resources are identified and as geneticscience evolves.


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Public Health Impact of Genetic TestsAssessed at the End of the 20th Century Asmore genetic tests are considered for populationscreening, and as associations among genes,environment, and common diseases arediscovered, the number of people who mightbenefit from genetic testing will most likelyincrease. Establishing the extent to which genetictests are currently used for clinical and publichealth purposes will provide a baseline for futuremonitoring of the impact of genetic tests onsociety. In response to this need, CDC classifiedthe 751 genetic tests listed in the GeneTestsdatabase as of November 2000 on the basis oftheir use for population-based testing and on theprevalence of the disease or condition beingtested. Of the 423 clinical tests, 51 had potentiallygreater impact on public health because of theiruse either in statewide newborn screeningprograms or in other population screeningprograms or because of their use in testing forcommon diseases with a prevalence of morethan 1 in 2,000 people. Among the 328 testsperformed for research purposes, only 18 met thecriteria for potentially greater public healthimpact. CDC concluded that at the end of the 20th

century, fewer than 10% of genetic tests wererelevant to public health. At the present time, themajority of genetic tests are used in diagnosis orgenetic counseling for rare, single-gene disordersin a limited number of people. However, inreviewing the diseases for which genetic tests are being developed in research settings, CDCforesees that tests for more common conditionsare likely to become more prevalent.

Standard Approach Being Developed toEvaluate Genetic Test Data In spite of thecontinued proliferation of genetic tests, only afew have been evaluated for clinical validity andutility. In a cooperative agreement with theFoundation for Blood Research, CDC isestablishing a standard approach for evaluatingdata on genetic tests. ACCE, named for the fourcomponents of evaluation—analytic validity;clinical validity; clinical utility; and ethical, legal,and social implications—is a model process forevaluating data on emerging genetic tests. Theprocess includes collecting, evaluating,interpreting, and reporting data about DNA andrelated testing for disorders with a geneticcomponent, then putting the data in a formatthat allows policy makers to have access to up-to-date and reliable information for decisionmaking. An important part of this process is theidentification of gaps in knowledge about thevalidity of genetic tests. Conditions to beexamined in the first year of this effort will includecystic fibrosis, hereditary hemochromatosis, andfactor V Leiden. Cancer-related genetic tests willbe assessed in the second year. The long-termgoal of this project is to develop a process thatcan be used by others to critically review genetic tests.

Prevalence and Penetrance Data to AidDecisions About Screening for HereditaryHemochromatosis Gene The National Healthand Nutrition Examination Survey (NHANES) isthe only nationally representative survey thatcollects samples suitable for use in geneticstudies; NHANES is unequaled as a resource to


Through a cooperative agreement with theFoundation for Blood Research, CDC is establishing astandard approach to evaluating data on genetic tests.

help medical and public health communitiesunderstand the role of genetic susceptibility inhealth outcomes for all segments of the U.S. population. In the first use of the NHANES III DNABank, CDC’s environmental health laboratorydetermined the number of people in the U.S.population who have gene variants associatedwith hereditary hemochromatosis (prevalence ofgene variants) and the probability that havingone of these variants will cause abnormalitiesrelated to excess iron absorption (penetrance ofthe gene variant). Hereditary hemochromatosis,the most common genetic disease in the UnitedStates, is a condition in which excess dietary ironaccumulates in organs such as the heart andkidneys and causes disease and death. This use ofthe NHANES III DNA Bank by CDC environmentalhealth scientists represents the achievement of apublic health milestone because prevalence andpenetrance estimates are needed to make publichealth decisions about whether or not to screenfor this genetic disorder.

Program Established to Improve thePrediction of Diabetes CDC, in collaborationwith the Immunology of Diabetes Society,established the Diabetes AutoantibodyStandardization Program (DASP) to improve the analyses of type 1 diabetes autoantibodies. Theseanalyses are crucial for predicting the onset ofthe disease. DASP evaluated the performance ofthe analytical assays at 47 major internationallaboratories in 15 countries and identified factors

that contribute to the highest sensitivity andspecificity for the assays. The results of meetingsand extensive data analysis indicated that thefollowing actions are needed to improve theseautoantibody measurements worldwide:developing CDC reference assays, developingreference materials to provide an accuracy basefor these measurements, conducting trainingprograms for performing these complexautoantibody assays, and obtaining normalcontrol sets (sets of serum from healthy people)to increase agreement of normal cutoff values.DASP is addressing the needed improvements sothat these analyses, which provide the mostsensitive and meaningful measures for accuratelytargeting program interventions for the preventionof type 1 diabetes, can identify more accuratelythose at risk.


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In the United States, about one million people, mostof them children, have type 1 diabetes, anautoimmune disease in which the body destroysthe pancreatic cells that make insulin.

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Major New Genetic Resource Launched CDC is collaborating with the Juvenile DiabetesResearch Foundation, the Joslin Diabetes Center,and George Washington University to determinegenetic risk factors for diabetes and itscomplications. In June 2001, CDC began testingand banking samples for researchers throughoutthe world through the Genetics of Kidneys inDiabetes (GoKinD) Study. In the course ofdeveloping methods for genotyping in the study,CDC encountered a major problem. One of thegenes, DQA1, has many different forms in thepopulation. If the gene is genotyped usingconventional direct sequencing, the sequencesfor some people are garbled and do not “line up”correctly, and the identity of the gene cannotbe determined.

CDC scientists solved the problem by separatingthe forms of the gene so that each could besequenced separately and by designing a novel spreadsheet so that individual forms of the genecould be identified easily from the sequence. Thecarefully characterized samples in this collectionwill provide high-quality genetic material fordetermining the contribution of candidate genesand genomic regions to the development of type1 diabetes and its complications. The GoKinDStudy will help scientists across the world understand the genetics of diabetic kidneydisease by providing them with sets of samplesthat help them learn how to identify people whomay be at risk of developing diabetes and itscomplications.

CDC Collaborates with Seven States to Identify Risk Factors for Birth Defects CDC iscollaborating with seven states on one of thelargest case-control studies ever conducted toidentify risk factors for birth defects. The NationalBirth Defects Prevention Study is unique in that itwill identify infants with major birth defects frompopulation-based registries using improved casedefinitions; interview mothers about theirmedical histories, environmental exposures, andlifestyles; collect cheek swabs from infants andparents to study gene-environment interactions;and establish a specimen bank to store biologic samples for future study. CDC’senvironmental health laboratory played a keyrole in developing and implementing qualitycontrol and proficiency testing programs forparticipating centers and serves as a referencelaboratory for any problems identified by the


In the Genetics of Kidneys in Diabetes study, CDC is testing andbanking genetic samples with which scientists can learn to identifypeople at risk for developing diabetes and its complications.

quality control program. CDC’s environmentalhealth laboratory not only developed andimplemented genotyping methods that ensurethe identity and quality of specimens but alsocoordinates the specimen bank. To date, cheek-swab specimens have been collected from 1,200study participants.

Human Genome Epidemiology NetworkExpanded The Human Genome EpidemiologyNetwork (HuGENet™), a global collaboration ofindividuals and organizations that develop andshare epidemiologic information about thehuman genome, has expanded its Web site withthe inclusion of HuGE Case Studies, the HuGE E-Journal Club, and the HuGE Published LiteratureDatabase.

The purpose of HuGE Case Studies is to trainhealth professionals in the practical applicationof human genome epidemiology and to helpreaders acquire conceptual and practical toolsfor critically evaluating the growing scientificliterature in specific disease areas. The knowledgegained from case studies will inform readers ofdiverse backgrounds on how epidemiologicdata can provide a scientific basis for usinggenetic information to improve health andprevent disease.

The HuGE E-Journal Club is an electronicdiscussion forum where new human genomeepidemiologic findings, published in the scientificliterature and included in CDC's Office ofGenomics and Disease Prevention's WeeklyUpdate, are abstracted, summarized, presented,

and discussed through a newly createdHuGENet™ listserv. The E-Journal Club presentsepidemiologic information in a standardizedformat and promotes discussion amongHuGENet™ members and other interested publichealth and clinical professionals on selectedarticles from the current published literature.

The HuGE Published Literature Database is adatabase of indexed epidemiologic literature ongene variant frequencies, gene-diseaseassociations, gene-gene and gene-environmentinteractions, and genetic test assessments.Database users are able to obtain a list ofrelevant articles by querying the database usingselected search terms. In addition, keyinformation from each article is provided, alongwith a direct link to PubMed's abstract of theresearch article.

These additional features offer a new dimensionto the HuGE Net Web site and provideopportunities for discussion among professionalsfrom clinical, public health, and other diversebackgrounds about human genomeepidemiology and about education for decision-making involving the use of genetic tests andservices.

Public Health Perspective Series PresentsComplex Information to a Diversified WebAudience Recent advances in human geneticsemanating from the Human Genome Projectpresent interesting challenges and opportunitiesfor both health communicators and educators.Information about genes, diseases, and


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environmental risk factors is complex and mustbe communicated in a way that is meaningful forprofessionals in public health and related healthprofessions. CDC has developed acommunication tool designed to presentscientific information in a clear and factualmanner to a diversified audience. Each PublicHealth Perspective is essentially a Web site thatcontains information and commentary on asingle topic. Complex topics such as hereditaryhemochromatosis, informed consent,pharmacogenomics, and genetic testing areexamined from a public health perspective.Readers will find both scientific information aswell as popular press news stories, videos, andcommentary geared to public healthprofessionals. This "something for everyone"approach allows readers to examine andunderstand discoveries of genetic variants;related disease outcomes; and complex social,legal, and ethical issues surrounding geneticdiscoveries. Perspectives are published by CDC'sOffice of Genomics and Disease Prevention(OGDP) in collaboration with other CDC officesand centers and are featured in the WeeklyUpdate every 4 to 6 weeks. The entire series ofPublic Health Perspectives can be found on theOGDP Web site at http://www.cdc.gov/genomics/info/perspective.htm.

International Health

CDC Responds to Complex AfghanCrisis Since September 11, 2001, anestimated 300,000 Afghan refugees have

entered Pakistan and up to 80,000 have enteredIran. They join the more than 3.5 million Afghanrefugees already in Pakistan and Iran. Theimmediate health concerns facing these refugeesare malnutrition, measles, malaria, and diarrhealdisease (including cholera). Rising to thechallenge of addressing these critical concerns,CDC staff members served as medicalcoordinators for the United Nations HighCommissioner for Refugees in Quetta, Pakistan,from September 2001 through January 2002. Inthis capacity, CDC staffers assisted in theplanning of new refugee camps inside Pakistanfor Afghan refugees; chaired coordination meetings between the Pakistani government and other organizations; and set health priorities, conducted assessments, and implemented a health information system for newly arrivingrefugees. CDC also furnished a staff member tocoordinate the measles immunization campaignin Afghanistan. This staff member is directing the measles campaign for the entire country. The World Health Organization estimated thatthe measles campaign will prevent the deaths of35,000 children. During the first week of thecampaign, more than 500,000 children wereimmunized. In addition to addressing immediatehealth concerns in Afghanistan, CDC inconjunction with the Vietnam Veterans ofAmerica Foundation is currently assisting the


Two men sit outside an Afghan refugee camp. CDCis addressing the Afghan crisis on several fronts,including improving refugee health, coordinatingthe measles immunization campaign, and partneringwith other organizations to resolve the problem oflandmines and unexploded ordnance.

United Nations Mine Action Program forAfghanistan to conduct several projects relatedto landmines and unexploded ordnance (UXO).Even before the recent conflict, Afghanistan wasmore heavily affected by landmines and UXOthan any other country in the world. Current CDCefforts include on-site technical assistance for apostconflict contamination assessment that willpave the way for the safe return of millions ofAfghan refugees and enable the entire country toincrease its agricultural output by reclaimingcontaminated land. Other projects include anational war-victims survey and several localcapacity-building projects, both of which will aidthe international community in improving thelives of all Afghans.

Winter Storm Effects Assessed in MongoliaDuring the winters of 1999–2000 and 2000–2001,many areas of Mongolia suffered from extremecold and greater-than-normal snowfall that led totransportation difficulties and loss of livestock.Because most rural families are dependent onlivestock for food and income, Mongolian healthauthorities were concerned that children’snutritional status would suffer as a result of theloss of animals. In collaboration with the WorldHealth Organization and the United NationsChildren’s Fund, CDC assisted the NutritionResearch Center of the Mongolia Ministry ofHealth in conducting a nationwide nutritionsurvey. One feature of the survey was that itmeasured for the first time the prevalence and


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A Mongolian family completes a nutritional survey with help from a CDC staffer.

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severity of several micronutrient deficienciessuspected to be endemic in rural Mongolia.Survey results indicated that acute protein-energy malnutrition was not common amongchildren 6–59 months of age in rural Mongolia.However, chronic protein-energy malnutritionaffected about one-third of children overall,anemia afflicted 30%, and vitamin D deficiencyappeared to be common. As a result of thissurvey, the Mongolian Ministry of Healthenhanced the pre-existing program of vitamin Aand D supplementation for young children. Inaddition, because this survey did not includerural residents who recently migrated to urbancenters, CDC plans to survey this very vulnerablepopulation in 2002.

Workshop Focuses on Adult MalnutritionAssessments CDC assisted in the organizationand implementation of a special workshop on assessment of adult malnutrition. The results ofthis workshop were a set of recommendations formeasurement of acute protein-energymalnutrition in adults in humanitarianemergencies. These recommendations will allowthe many nongovernmental organizations andUnited Nations agencies concerned withmalnutrition and feeding programs to moreaccurately measure the extent of malnutrition inthis largely neglected age group. Suchmeasurement will help reduce the frequencywith which adults are overlooked when assessingnutritional status. CDC will play an active role incoordinating evaluation of these recommendations

and in training others to incorporate them intonutrition assessment activities.

Refugees in Guinea Given Health andNutrition Aid From January through May 2001,CDC staff members served as United Nations(UN) High Commissioner for Refugees medicalcoordinators in Guinea. CDC coordinated healthcare and nutrition activities for all refugeesthroughout Guinea while working with theGuinean government, nongovernmentalorganizations, and other UN agencies. A sentinelhealth information system implemented by CDCin refugee camps produced data that formed abaseline of information on illnesses and deaths. CDC also conducted a survey of familiesregistering in a new refugee camp. Surveyorsgathered data on illness, injury, and death;reproductive health; and mental health.

Refugee Mental Health Surveys Conducted inThailand CDC conducted two surveys assessingthe prevalence of mental illness related totraumatic experiences among the Karenni Staterefugees in three camps in Mae Hong Son,Thailand. One study focused on the experience ofthe general population and the other studyreviewed the experiences among land mineinjury survivors. The latter was the firstepidemiologic mental health assessmentconducted among land mine injury survivors.CDC's survey results will help the InternationalRescue Committee develop culturally appropriateand ultimately sustainable strategies and


intervention programs for addressing thesemental health issues.

Training Manual for Humanitarian AssistanceDeveloped In 1997, a group of humanitarianorganizations launched the Sphere Project toimprove the quality of assistance provided topeople affected by disasters and to enhance theaccountability of the humanitarian system indisaster response. CDC recently drafted theSphere Training Manual to accompany The SphereProject Humanitarian Charter and MinimumStandards in Disaster Response. The objective ofthe manual is to provide training to individualsand organizations involved in humanitarianassistance on the public health priorities andminimum standards during emergencies. Thistraining is expected to minimize preventablediseases in emergency situations. The manual willbe piloted in 2002.

Mexico and Peru Welcome IntensiveEnvironmental Epidemiology Training CDCconducted two week-long training courses at theNational Institute of Public Health of Mexico inCuernavaca. The first course was an appliedcourse designed to train health officials onpractical skills needed to perform health needsassessments and environmental exposureassessments in communities affected by naturaldisasters. The second course was anenvironmental epidemiology course that coveredthe fundamentals of epidemiology, the specificsof environmental epidemiology, and the basicson how to design and conduct environmentalepidemiologic studies. This course was also

taught in Lima, Peru, and comprised five lecturesdesigned to address the specific environmentalepidemiology needs of Latin American countries.The intention of the latter course was to enableeach module to stand alone so that a student orgroup could choose the specific module(s) thatbest met their needs. The course is beingconverted into a distance-based learning coursefor Spanish speakers.

CDC Contributes Biomonitoring Expertise toInternational Agreement In fiscal year 2001,CDC continued to assess human exposure topersistent organic pollutants (POPs) and to determine the human health effects of suchexposure. POPs are chemicals that persist in theenvironment, bioaccumulate through the foodchain, and pose a risk of causing adverse effectson human health. These chemicals, which include


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A CDC laboratorian injects calibration compound into a massspectrometer used to measure levels of persistent organicpollutants in human samples.

polychlorinated dibenzo-p-dioxins, polychlorinateddibenzo furans, polychlorinated biphenyls, andnine chlorinated pesticides, were the subject ofthe Stockholm Convention Treaty, which calledfor global actions to reduce and eliminatereleases of these chemicals. The treaty sets out control measures covering the production,import, export, use, and disposal of POPs.Governments are to promote the best availabletechnology and practices for replacing existingPOPs while preventing the development of newones. More than 100 nations, including theUnited States, signed the treaty in May 2001.Thetreaty has yet to be ratified, but CDC is helpingformulate guidelines to assess the effectivenessof the treaty after it is ratified and implemented.

Support Provided for InternationalMicronutrient Assessment Programs Duringthe past year, CDC provided technical andanalytical support for many international studiesthat assessed the nutritional status of thepopulation. These studies included a nationalnutrition survey for iron, vitamin A, and iodinedeficiency in Malawi; an anemia study amongchildren in Kenya; a vitamin A follow-up survey inChuuk State, Micronesia, that involved measuringlevels of lead, iodine, folate, and iron indicators; ananemia study in Mongolia; a national iodine andanemia survey in the Ukraine; and a nationalvitamin A survey in Brazil.

CDC’s environmental health laboratory alsoprovided technical support and training tolaboratories in some of the countries thatperformed these analyses and was actively

involved in designing the surveys, selectingappropriate indicators of nutritional status,and helping with the logistics of setting up thesurvey or study. CDC’s involvement helps toensure that quality data are obtained. These dataare needed for making key public healthdecisions, such as whether to introduce afortification or supplementation program, andfor determining whether such decisions have hadthe desired impact.

International Iodine Laboratory NetworkEstablished For more than a billion peoplethroughout the world, getting enough iodine intheir diets is a major problem. Iodine deficiencydisorders (IDDs) are the main cause ofpreventable retardation, and the most cost-effective and sustainable way to eliminate IDDs isto iodize all edible salt. The public health goal is


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Malawi health care workers used this central area to collect fingerstick samples of whole blood fromparticipants in a nutrition survey.

for 90% of all households in the world toconsume adequate amounts of iodized salt. Thekey to reaching that goal is assessing iodinestatus by measuring iodine’s concentration inurine, but not all laboratories in the worldmeasure urinary iodine or salt iodine the sameway. That makes it difficult to monitor iodinestatus and salt iodization in many countries andregions. Thus, researchers, public healthprofessionals, and policy makers from 31countries attending an international conferencein Bangkok, Thailand, in May 2001, agreed toestablish an international iodine laboratorynetwork. The conference, jointly sponsored byCDC, the World Health Organization, the UnitedNations Children’s Fund, and the MicronutrientInitiative, included a review and discussion ofcountry experiences and technical and practicalbarriers to analyzing iodine in both urine and saltin developed and developing countries.

This international iodine laboratory network willcomprise resource laboratories and a globalexternal quality assurance program for bothurinary and salt iodine. CDC is currently workingwith international organizations to selectresource laboratories from various regions forinclusion in the global network. Programs tomonitor salt iodization and to evaluate the iodinestatus of at-risk populations have begun in mostcountries. The indispensability of reliablelaboratory data to such programs is beyondquestion. An international iodine laboratorynetwork will greatly improve the quality of datathat regional and national laboratories produce

and thus enhance the success of programs toeliminate IDD worldwide.

Training Workshop Conducted for EasternMediterranean Region Countries Inanticipation of the soon-to-come fortification offlour in several eastern Mediterranean nations,CDC organized and conducted a trainingworkshop on epidemiologic and laboratorymethods for conducting a national surveyfocusing on indicators of iron status.Epidemiologists, nutritionists, and laboratoryscientists from eight countries in the regionparticipated in the 2-week workshop thatprovided theoretical background and hands-ontraining. This well-received workshop will helpcountries develop national nutrition surveys andimplement surveillance systems to track theimpact of nutrition programs. A secondworkshop took place in March 2002.

Improving the Diagnosis,Treatment, and Prevention ofChronic Diseases

Tobacco-Related Issues

Lower Environmental Tobacco SmokeExposure Found in U.S. Population Theuse of tobacco products is the leading

cause of preventable morbidity and mortality inthe United States. In addition, exposure toenvironmental tobacco smoke (ETS) is a


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significant health risk for many nonsmokers,especially vulnerable groups such as pregnantwomen and children. Beginning with theNational Health and Nutrition ExaminationSurvey (NHANES) III (1988–1994), CDC’senvironmental health laboratory analyzed serumcotinine levels using a sensitive methoddeveloped at CDC for NHANES participants aged4 years and older to evaluate tobacco smokeexposure. During fiscal year 2001, CDC’senvironmental health laboratory reported serumcotinine results from the analysis of 3,242individuals who participated in NHANES 1999.Groups previously found in NHANES III to be atelevated risk for ETS exposure, including non-Hispanic blacks, males, and children, also hadrelatively higher exposure levels in NHANES 1999.However, ETS exposure levels of the overallpopulation in 1999 were much lower than in NHANES III, documenting a significant and continuing decline in the exposure of the U.S. population to ETS during the past decade andreflecting substantial progress by the publichealth community in reducing ETS exposure.

New Cotinine Analysis Measures PassiveExposure Levels Among Pregnant WomenPrevious studies have suggested that exposure ofpregnant women to environmental tobaccosmoke may contribute to adverse birthoutcomes, including an increased risk of givingbirth to babies with low birth weights. During thepast year, CDC’s environmental health laboratorycompleted data analysis in a study of cotininelevels measured by liquid chromatography/atmospheric pressure ionization tandem mass

spectrometry in 2,777 serum samples from agroup of women in the middle trimester ofpregnancy who were enrolled in California’sprenatal screening program. Using this novelmethod enabled CDC to examine passiveexposure levels that were previously inaccessible.In this study, after controlling for gestational ageand five other covariates, scientists found aninverse dose-response effect between logcotinine and mean birth weight (-110 g, p = 0.04)over the entire range of log cotinine values. Theresults indicate that the odds of an adversepregnancy outcome increased 2.4-fold (p = 0.01)over the range of log cotinine values. Theseeffects are larger than have previously beenreported for nonsmoking women, a finding thatmay reflect a more accurate assessment of thetrue “nonexposed” reference population.

Cigarette Brand-Switching from High- to Low-Tar Cigarettes Found to Be IneffectiveConsiderable evidence exists that people whosmoke so-called “light” cigarettes are exposed toas much nicotine as are smokers of higher yield(“full-flavor”) cigarettes. However, the effect ofbrand switching on exposure to other toxicsubstances in tobacco, including “tar”(carcinogenic aromatic amines) and tobacco-specific nitrosamines, is limited. CDC’senvironmental health laboratory collaborated ona study with the University of California, SanFrancisco (UCSF), to examine the biochemicalexposures of a group of 20 volunteer smokerswho switched between cigarettes of differentyields in a study with a multiweek crossover,A-B-A design. During the past year, the


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CDC continued its investigations of the healtheffects of cigarette smoking with several importantstudies related to hazardous constituents in tobacco.

laboratory completed this study, including theanalysis of the tobacco-specific nitrosamines4-(methylnitrosamino)-1-(3-pyridyl)- 1-butanol (NNAL), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol-glucuronide (NNAL-glucuronide), and urinary 4-aminobiphenyl, in all participants at each timeinterval. Additional markers were measured atUCSF. As expected, the preliminary datasuggested that “low tar and nicotine” cigarettesdid not produce significant reductions inexposure to these hazardous components oftobacco smoke.

CDC Examines Prenatal Exposure to Tobaccoand Risk for Sudden Infant Death SyndromePrenatal exposure to tobacco smoke increasesthe risk for sudden infant death syndrome (SIDS)by a factor of twofold to fourfold. CDC’senvironmental health laboratory designed astudy to evaluate how prenatal nicotine exposureinfluences the newborn heart rate by continuouslymonitoring cardiac rates immediately after birthand relating the findings to cotinine concentrations incord blood as an index of recent, prenatalnicotine exposure. Results indicated that infantswith serum cotinine levels above a cutoff of 6nanograms per milliliter (ng/mL) differedsignificantly from nonexposed infants (cotininelevels < 0.05 ng/mL) in maximum heart rate,range, and variance. Prenatal nicotine exposureaccounted for 48% to 53% of the difference inthe heart-rate variables. These findings indicate that newborns exposed prenatally to nicotine are

less able to maximize their heart rate and thustheir cardiac output during reduced inspirations,resulting in lower oxygen levels and puttingthem at higher risk for SIDS.

Tar, Nicotine, and Carbon Monoxide Levels inInternational Cigarette Brands AnalyzedNicotine, tar, and carbon monoxide (CO) wereconsidered for many years to be good markersfor the addictiveness (nicotine), carcinogenicity(tar), and toxicity (CO) of tobacco smoke.Although scientists now know that evaluatingtobacco smoke requires more sophisticatedanalysis, these substances are still the primarymarkers of the dangers posed by using tobacco.During the last year, CDC laboratorians measurednicotine, tar, and CO smoke yields from 77cigarette brands purchased in 36 countries. Thegoal of this study was to compare these yields inmainstream smoke from cigarettes manufacturedby a leading U.S. transnational corporation withnon-U.S., locally popular brands to determinewhether there were any differences associatedwith cigarette brands consumed in differentgeographic regions. Not unexpectedly, resultsshowed large differences in mainstream smokedeliveries, which varied from 6.8 to 21.6 mg oftar/cigarette, from 0.5 to 1.6 mg of nicotine/cigarette, and from 5.9 to 17.4 mg of CO/cigarette.These findings suggest that cigarettes fromcertain regions tend to have higher smokedeliveries of tar, nicotine, and CO than docigarettes from other regions.


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In a study of how prenatal nicotine exposureinfluences newborn heart rates, CDC found thatpregnant women who smoke are greatly increasingtheir babies' risk for sudden infant death syndrome.

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Diabetes

CDC Collaborates with Manufacturers toImprove Clinical Laboratory Testing Reliablelaboratory results are the key to defining risk forand monitoring the progression of chronicdiseases and their associated complications.Working with manufacturers of diagnostic assaysin calibrating and standardizing their methods isthe most efficient and direct approach toimproving laboratory testing. CDC conductedthree manufacturer-focused workshops in 2001to address measurement issues for hemoglobinA1c (HbA1c), blood glucose for diabetes, andhigh-sensitivity C-reactive protein (hsCRP) forcardiovascular disease (CVD). The workshopsgave manufacturers the opportunity to commenton new performance criteria for certifying theperformance of assays used to measure HbA1c,which provides a long-term estimate of glycemiccontrol; to learn about CDC’s program toharmonize the performance of blood glucosemonitoring devices; and to discuss approaches tostandardizing measurements for hsCRP, whichcan be a powerful predictor of CVD.

Cardiovascular Disease

Cholesterol Reference Method LaboratoryNow Certifies Triglyceride MeasurementsThrough its collaboration with the NationalHeart, Lung, and Blood Institute, CDC continuesto provide external quality assessment andstandardization support to 97 laboratories involved

in investigating the causes of cardiovascular disease(CVD) and its complications. Furthermore, CDC’sCholesterol Reference Method LaboratoryNetwork (CRMLN) continues its work with clinicallaboratories and manufacturers of diagnosticproducts to certify the performance of theiranalytical systems for measuring lipids andlipoproteins. In collaboration with Italianscientists, CRMLN also expanded its services toinclude certification of triglyceride measurements.As a result, CRMLN can now provide manufacturerswith the complete lipoprotein profile that isrecommended by the National CholesterolEducation Program for assessing a person’s risk for CVD.

Bone Disease

Method Developed to Measure Biomarkers forBone Disease As the U.S. population ages,diagnosing, treating, and monitoring metabolicbone disease will become a major public healthissue. With the development of powerful newdrugs, effective treatment of bone disorders ispossible. The use of refined techniques inmeasuring bone-mineral density, as well as theuse of biochemical bone markers to measurebone formation and resorption, help physiciansdetect these disorders more accurately andmonitor treatment more efficiently than in thepast. However, the lack of standards andreference materials for bone markers makes itdifficult to compare results obtained by differentlaboratories, so the value of using biochemicalbone markers as a diagnostic tool is debatable. To


Two biomarkers used to manage bone diseases andassess bone metabolism can now be measured withgreat accuracy using a new urinary method that CDCdeveloped.

address this problem, CDC is working to establisha system for obtaining consistent and uniformresults across methods and sample matriceswhen measuring these markers. In 2001, CDCscientists completed development of a highlyaccurate, specific, and sensitive urinary method tomeasure two biomarkers, pyridinoline anddeoxypyridinoline, that are used to manage bonediseases, such as osteoporosis, and to assess bonemetabolism in epidemiologic studies. Currently,CDC’s environmental health laboratory is the onlyplace in the world where these markers can bemeasured with such accuracy.

Age-Related Vision Loss

Antioxidant Vitamins and Zinc Reduce Risk forAge-Related Vision Loss Believing that visualimpairment is unavoidable as they get older,many people are unaware that they are simply atrisk for age-related vision loss. Moreover, resultsfrom an 11-year clinical trial show that a high-dose combination of vitamins C and E,betacarotene, and zinc could reduce that risk.Since 1990, CDC, in collaboration with theNational Eye Institute (NEI), has participated in amajor clinical trial called the Age-Related EyeDisease Study. This randomized, placebo-controlled trial of nutritional supplements forpreventing macular degeneration involved 4,757participants aged 55 through 80 years in 11clinical centers nationwide. Study participants

were given one of four treatments: (1) zinc alone,(2) antioxidants alone, (3) a combination ofantioxidants and zinc, or (4) a placebo. CDCprovided key data to support the effectiveness ofselected antioxidant supplements in delaying theprogression of age-related macular degeneration(AMD), the leading cause of visual impairment and blindness in the United States. CDC scientists measured serum concentrations of vitamins C, A,and E; carotenoids; zinc; copper; and lipids toensure compliance and determineconcentrations achieved in study participants.NEI used the data to determine that people athigh risk of developing advanced AMD loweredtheir risk by about 25% when treated with a high-dose combination of vitamins C and E,betacarotene, and zinc. In the same high-riskgroup, which included people with intermediateAMD or advanced AMD in one eye only, thenutrients reduced the risk for vision loss causedby advanced AMD by about 19%. The nutrientsprovided no apparent benefit for thoseparticipants with either no AMD or early AMD.

As baby boomers age, AMD will become a moreprevalent cause of blindness in our nation thandiabetic retinopathy and glaucoma combined.The causes of the disease are unclear, butoxidative damage to the retina may be involved.The supplementation phase of the study endedin 2001; the follow-up phase will continue for aminimum of 5 years.


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In an 11-year study involving 4,757 participants, CDCand the National Eye Institute demonstrated thattaking a high-dose combination of vitamins C and E,betacarotene, and zinc can reduce a person's risk ofexperiencing age-related vision loss.

Newborn Screening

Tandem Mass Spectrometry Signals BigChanges for Newborn Screening Theability of tandem mass spectrometry

(MS/MS) to scan a single sample for a large groupof inherited disorders promises to change theway newborn screening is done in the nearfuture. Using this technology, laboratories candetect more than double the number ofmetabolic disorders than can be detected usingother dried–blood-spot technologies alone.Advocacy groups are strongly urging the use ofthis technology, arguing that MS/MS can detect awide variety of devastating conditions and thataffected children have a better chance of survivalthrough detection and early intervention. This year,CDC issued recommendations and guidance aimedat helping newborn screening programs implementand use this technology. CDC’s environmental

health laboratory also piloted a proficiency-testing (PT) program for detecting disordersusing MS/MS. Currently, 21 laboratories in 11countries and all 15 programs in the UnitedStates participate in this new PT program. Initialdata, however, revealed discrepancies inmeasurements. These discrepancies were tracedto a calibration problem and were resolved, thusincreasing harmonization in measurementsamong all participants and building confidencein the validity of the test results using this new technology.

Performance Is Improved for Filter-PaperBlood-Collection Device The filter-paper blood-collection device has achieved the same level ofprecision and reproducibility that analyticalscientists and clinicians have come to expectfrom standard methods used to collect andaliquot blood specimens. The device involvessome level of imprecision that can be measuredto standardize the device and to minimizevariations in measurements. Understanding andcontrolling sources of imprecision are essential tothe appropriate analytical use of specimens thatare collected on filter paper; thus, CDC developedcriteria that contribute to a national standard forensuring filter paper’s uniform performance.Without the criteria, laboratories would beunable to perform reliable quantitativemeasurements. During fiscal year 2001, CDCevaluated several production lots of filter paperfrom commercial sources before their release tonewborn screening programs and determinedthat all lots met approved performance criteria.Activities of this validation program for filter


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Using tandem mass spectrometry, laboratories performing newbornscreening tests can detect twice as many metabolic dosorders ascan be detected using other dried–blood-spot technologies.

A baby’s heel is stuck to obtain blood to screen formetabolic and other disorders. CDC is the soleprovider of comprehensive external quality assuranceservices for newborn screening programs.

paper have improved performance of the deviceand its acceptance for use in a variety of assays.

Quality Ensured for Newborn Screening TestsCDC’s Newborn Screening Quality AssuranceProgram ensures that newborn screeningservices provided by participating laboratoriesare accurate and of the highest quality. In thepast year, 256 laboratories in 46 countriesparticipated in external quality assurance (EQA)activities for inherited metabolic disorders. Forty-nine new participants, including the Ukraine,Luxembourg, Colombia, Turkey, and Denmark,were enrolled in the EQA program. This programprovides a check for laboratories, givingimmediate feedback to those who misclassifyspecimens so that they can take timely correctiveaction. Through close interaction with screeninglaboratories, CDC helps to ensure that affectedbabies are correctly identified, cases of diseaseare not missed, and the number of false-positivetest results is minimized. CDC is the sole providerof comprehensive EQA services for newbornscreening. In fiscal year 2001, CDC expanded theprogram to include EQA services for anadditional 20 disorders that screening programscan detect using new technologies.

Primary Immunodeficiency Diseases GetPublic Health Scrutiny To identify emergingtargets for prevention research, CDC convened aninternational conference on immunodeficiencydiseases caused by single-gene disorders.Attendees reported that children born with severe combined immunodeficiency disorders

(SCIDs) can be rescued from early death by newinterventions, such as stem-cell transplants (fromdonor bone marrow or umbilical cord blood) andgene-replacement therapy. Effective interventionmust begin during the first few months of lifewhile immunity transferred from the mother stillprotects the baby. Attendees also called on CDC to investigate newborn screening for SCIDsbecause of this narrow window of opportunityand the invariably fatal outcome of untreateddisease. CDC identified candidate tests and isevaluating their technical feasibility.

Blood Spots from Newborns Used to Test forDiabetes Risk During 2001, scientists supportedby CDC tested dried blood spots obtained frommore than 10,000 newborns in Washington Stateto identify a cohort at higher risk than othernewborns for type 1 diabetes. The dried bloodspots had been collected for newborn screeningand stored by the Washington State Departmentof Health, making this the first time that samplesfrom a newborn screening repository were usedfor diabetes research. CDC also collected 12,000dried blood spots from other people with knowngenetic risk factors to use as reference materials.Using these materials, CDC designed a proficiency-testing program involving six diabetes researchcenters in Europe and the United States. Thepurpose of the program is to help ensure theequivalency of performance in all centers thatconduct diabetes research. The program will beexpanded to additional centers that undertakesimilar population-based studies on type 1 diabetes.


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An international conference convened byCDC focused on immunodeficiencydiseases caused by single-gene disorders.

Environmental Health Studies

CDC Investigates Nevada CancerCluster In February 2001, the healthofficer for the state of Nevada reported

a statistically significant increase in the incidenceof acute lymphocytic and myelocytic leukemia(ALL/AML) in Churchill County. Local residentshad expressed concern about pesticides appliedto agricultural fields, pesticide run-off from thesefields to irrigation ditches in which local childrenswim, arsenic in drinking water, and jet fuel usedat the Fallon Naval Air Station. Fifteen childrenwere diagnosed with ALL or AML from 1997through 2001; for the previous decade, theexpected rate of occurrence for the illness was2.4 cases per 100,000 children, or one caseevery 5 years.

The Nevada State Health Division asked CDC toevaluate risk factors or etiologic exposures linkedto this cluster of childhood leukemia and todesign and conduct a cross-sectional exposureassessment of selective contaminants usingenvironmental and biologic specimens collectedfrom the case families and a referencepopulation. The Agency for Toxic Substances andDisease Registry (ATSDR) was also asked toconduct an exposure-pathway assessment.

From August to November 2001, CDC operated afield office in Fallon, Nevada, that was equippedwith a temporary laboratory facility that allowedprecise aliquoting of blood and urine samplesprior to shipment to CDC’s environmental health

laboratory. Staff from the Nevada Division ofEnvironmental Protection coordinated fieldteams to collect environmental samples fromstudy subjects’ current and previous residences.Samples were collected from more than 130homes and from approximately 200 people,including case children, their parents, and theirsiblings as well as from reference children andtheir parents.

In December 2001, CDC began analyzingquestionnaire, biologic, and environmental data.CDC scientists will assess chemical and radiologicexposures among participating children and theirfamilies. CDC’s environmental health laboratory isanalyzing urine and blood samples for thepresence of 132 chemicals and is also measuring levels of 15 volatile organic compounds in theblood of the affected children and their families.CDC laboratory scientists will assess variations ingenes involved in metabolizing toxic substancesand any DNA repair occurring as a result ofenvironmental exposures. CDC scientists will alsoextract DNA from blood and buccal cells andstore it for future studies.

A statistical analysis group formed within CDCbegan refining an analysis plan that includescross-sectional analysis for exposure assessmentand a comparison of case and control data. CDCis working with ATSDR to use geographicinformation system technology to map thelocations of study subjects’ homes and ofpossible points of contamination to determinelikely exposure routes. A committee comprisingrepresentatives from CDC and ATSDR, the United


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The small town of Fallon, Nevada, is the site of anintense investigation into the causes of a higher-than-expected number of leukemia cases among area children.

States Geologic Survey, the Nevada State HealthDivision, and the Nevada Department ofEnvironmental Protection will interpret analyticalresults and inform Nevada’s state epidemiologistif elevated levels of environmental contaminantsare found in any samples.

Data from the investigation will be useful inevaluating the contribution of environmentalfactors or chemical exposures to the elevatedincidence of ALL/AML among children inChurchill County. CDC will release a finalsummary report in August 2002.

Radiation Studies

Nevada Test Site Study Takes a StepForward CDC currently has acooperative agreement with the

University of Utah to conduct a follow-up studyof thyroid disease among a cohort of peoplepotentially exposed to fallout—specificallyiodine-131—from nuclear weapons testing at theNevada Test Site. This cohort was initiallyidentified and examined from 1965 through 1970and included children aged 12 through 18 yearswho were enrolled in schools in WashingtonCounty, Utah; Lincoln County, Nevada; andGraham County, Arizona. The proposed study willbe the third examination of this cohort within thelast 35 years. A 1985 follow-up study identified aweak association between exposure toradioactive iodine in nuclear fallout and benign

thyroid neoplasms. The Utah Thyroid DiseaseCohort Study received both Office ofManagement and Budget and InstitutionalReview Board approval this year, moving it onestep closer to implementation. Currently, theNational Academy of Sciences (NAS) is reviewingthe scientific protocol. The study will moveforward when recommendations from the NASreview are addressed and a sound scientificprotocol is in place.

Workshop Held on Thyroid Disease ScreeningWith support from CDC and the National CancerInstitute (NCI), the Advisory Committee onEnergy-Related Epidemiologic Research (ACERER)sponsored a workshop entitled "TargetedScreening for Thyroid and Parathyroid Disease ina Higher-Risk Population Exposed to Iodine-131."The goal of this workshop was to provide ACERERmembership with information and guidance sothat they can make informed recommendationsabout such screening to the Secretary of Healthand Human Services (HHS). CDC staff, with inputfrom workshop participants and the Office of theSecretary, have prepared and transmitted asummary of the proceedings to all ACERERmembers and consultants and workshopparticipants, including officials from CDC, theAgency for Toxic Substances and DiseaseRegistry, NCI, HHS, and the Department of Energy.

CDC Completes Research in FernaldCommunity One site at which CDC hasresearched the health effects of radioactivecontaminants from Department of Energynuclear production facilities is Fernald, Ohio. For


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several decades this site, which is the former FeedMaterials Production Center, served as a uranium-processing facility for the U.S. nuclear weaponsproduction complex. Since requested to do so byCongress in 1988, CDC has estimated off-siteexposure to community members, conducted riskanalyses of several types of cancer, and assessedthe feasibility of conducting a scientifically soundepidemiologic study (subsequently determinednot to be feasible). On the basis of the results of adose reconstruction study, CDC determined thatradioactive substances, including uranium,thorium, radium, and radon daughter products,migrated off site and exposed members of thesurrounding communities. What was unexpected,though, was CDC’s finding that radon releasedfrom radium-containing waste stored on site—not uranium—created the most significantradiologic exposure for the communities

surrounding the site. A CDC assessment of riskfrom these exposures concluded that thenumber of lung cancer deaths in the assessmentpopulation may increase by 1% to 12% as a resultof exposure to radioactive material released fromthe site from 1951 through 1988.

CDC shared with community membersinformation from risk analyses about potentialhealth effects from off-site exposures. Thisinformation formed a basis for communityseminars that the Agency for Toxic Substancesand Disease Registry (ATSDR) developed.Although CDC has no future work planned in theFernald community, CDC staff will continue toreview research findings relating to health effectsamong community members and the possiblelinks to the Fernald site. After consulting ATSDR,CDC discontinued its federally chartered advisorycommittee at the site this year.

Scientists Consider Public HealthConsequences of Radioactive Fallout Incollaboration with the National Cancer Institute,CDC scientists have prepared a report on thefeasibility of conducting a study of the health consequences to the American people from radioactive fallout due to historic U.S. and globalatmospheric nuclear weapons testing. For thefirst time, estimates have been made ofpreliminary doses and health risks from exposureto radioactive fallout from nuclear weapons testsconducted in the atmosphere from 1951 through1962. This large two-volume report, whichcurrently is undergoing department review, will


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Silos 1 and 2 of Operable Unit 4 at Fernald, Ohio. CDC’s assessment ofhealth risk to the nearby communities found that radon from radium-containing wastes in these silos was the most significant source ofradiologic exposure for the public.

undergo an extensive scientific peer review infiscal year 2002. Congress and the Department of Health and Human Services will review theresults of this feasibility study to determinewhether the federal government should pursue a more comprehensive study of health consequences.

International Radiation Data to Be MadeAvailable to Researchers A number ofunintentional or operational releases ofradioactive material to the environment haveoccurred at locations around the world. Radiationdata compiled as a result of these events can beused in the development and testing ofmathematical models that are used to assess thepublic health impact of radioactivity releases tothe environment. With support from CDC, anumber of international sets of data that can beused for this purpose have been identified andcompiled. CDC will post these data sets on the Internet during calendar year 2002 so that

radiation health scientists can use them todevelop and test methodologies for assessingthe public health effect of various types ofradionuclide releases into the environment.

Public Receives Estimates of Toxic MaterialsReleased at the Savannah River Site CDCreleased to the public and posted on the Internet(http://www.cdc.gov/nceh/radiation/savannah/default.htm) a report describing estimates of theamounts of radionuclides and chemicals historicallyreleased into the environment by the SavannahRiver Site nuclear weapons facility. The releaseestimates provided in this report for radioactiveiodine and plutonium are higher than theestimates previously provided by the SavannahRiver Site. CDC’s ongoing Savannah River SiteEnvironmental Dose Reconstruction Project willuse these results to estimate the health risks topeople of chemicals and radioactive materialspreviously released from the site.


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CDC's estimates of amounts of some hazardous materials released to air and water at the Savannah River Site (SRS), a U.S. Department of Energysite in close proximity to wetlands, agricultural land, and woodlands and underlain by an aquifer, are higher than those estimates previouslyprovided by SRS.

Agencies and Stakeholders Collaborate toImprove Advisory Committee Process Publicinput is essential to CDC and the Agency for ToxicSubstances and Disease Registry's (ATSDR's)research and public health activities involvingcommunities and workers at nuclear weaponsproduction facilities. Consequently, community-agency partnerships have been establishedthrough a system of site-specific citizen advisorysubcommittees (referred to as health effectssubcommittees). CDC recently completed anevaluation of this advisory process, the goal ofwhich was to improve the effectiveness of theprocess. The evaluation addressed issues such asthe effectiveness of the subcommittees inproviding advice and the agencies' use of thisadvice, the effect of the advisory process onresearch credibility and trust, and the role of thesubcommittees in outreach activities. Anotherissue that was addressed was the adequacy ofresources. This evaluation used a participatoryapproach and included representatives fromCDC, ATSDR, the subcommittees, and anindependent evaluation contractor. Thecontractor compiled the key findings. On thebasis of these findings, the contractor developed17 recommendations for agency staff andsubcommittee members to improve thesubcommittee process. The endeavor was one ofthe first multisite evaluation projects guided byCDC's Framework for Program Evaluation in PublicHealth. CDC, ATSDR, and subcommittee membersare continuing their collaboration in improvingthe subcommittee process as they review andimplement the recommendations from thisevaluation.

Veterans’ Health Activities

Research Programs Initiated to ImproveHealth Risk Communication CDCawarded $337,693 to Rutgers University

for the project “Improving Health RiskCommunications to Prevent UnexplainedIllnesses Related to Military Deployments.” Thisproject will assess knowledge, attitudes, andbeliefs of healthy and ill Gulf War veterans andcurrent active duty military personnel aboutchemical, biologic, and radiologic agents. Theproject will develop and evaluate riskcommunication materials about these agents as well. CDC also awarded $461,177 to the Henry M.Jackson Foundation for the project “Health-eVOICE: Optimized Implementation of a SteppedClinical Risk Communications Guideline.” Thisproject will develop and evaluate an interactive,Web-based distance-learning tool for improvingcommunication between Department of Defensehealth care providers and veterans regardingdeployment-related health concerns.

Mortality Follow-Up Study of Vietnam VetsInitiated This study will collect vital status datafrom the National Death Index Plus, the VeteransAdministration Beneficiary Identification andRecord Locator System, and the Social SecurityAdministration Death Master File regarding the18,313 veterans who were eligible to participatein CDC's Vietnam Experience Study. CDCdeveloped a protocol and obtained InstitutionalReview Board approval in November 2001. Datacollection began in December 2001. The purpose


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of the study is to determine if Vietnam veteransare experiencing any excess mortality comparedwith their nondeployed peers. Back in the 1980s,CDC conducted the Vietnam Experience Study,which assessed both mortality and morbidity ofa cohort of U.S. Army Vietnam veterans and acomparison group of U.S. Army personnel whoserved at the time of the Vietnam War but whowere not deployed to Vietnam. The originalmortality component assessed mortality through1983. This study will conduct a follow-up todetermine mortality through 1999. Results areexpected by the end of 2002.

Web Library to House Gulf War-Related HealthDocuments CDC provided $200,000 for thedevelopment of a Web-based research library ofreports and articles about government-sponsored research on the health effects ofmilitary deployment during the Gulf War. Thecentralized library will be an easily accessibleInternet tool designed to meet the needs ofresearchers, health care providers, veterans, andthe general public. The library is being createdthrough an interagency agreement between CDCand the Office of the Special Assistant to theUnder Secretary of Defense (Personnel andReadiness) for Gulf War Illnesses, MedicalReadiness, and Military Deployments. A workableWeb site is expected to be completed in 2002.


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Asthma

CDC Reaches Out to MedicallyUnderserved Children with AsthmaCDC contracted with the Alliance of

Community Health Plans to implement theNational Cooperative Inner-City Asthma

Study intervention in 23 clinics servingcommunities with medically underserved

children who have moderate or severepersistent asthma. The primarypurpose of the intervention is totranslate asthma knowledge intoskills and behavior changes that willreduce asthma severity andfrequency of symptoms in childrenby encouraging them, togetherwith their family members (or othercaregivers), to assume directresponsibility for controlling

symptoms. The severity and cause ofeach child’s asthma varies, as does

each family’s capacity to takeresponsibility for managing the disease.

This project is designed to work with theseunique differences to achieve the greatest

possible level of improvement for each child.The project goal is to work with 60 children the

first year and 80 children yearly thereafter.

The El Rio Health Center in Tucson, Arizona, which is one of theInner-City Asthma Intervention (ICAI) projects, was first funded in March2001. CDC provided $100,000 to the center for its first year of activities. Asof November 2001, the center had enrolled more than 60 children and hada waiting list of children and families who want to be part of the program.

The key person in the intervention is the asthma counselor, who uses astandardized assessment tool to identify risk factors for the four problems

Success Stories

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slated for intervention: access to primary care forasthma, adherence, behavior, and environment.The first 2 months of the intervention aresemistructured, involving both group andindividual sessions with child and family.Activities are then tailored to each family,focusing on environmental, medical, or specialtraining, as needed. As the counselor tailors theintervention and learns of a family’s specificcircumstances, problems are often identified thatcan’t be dealt with directly. The counselor refersthese types of issues either back to the child’scare provider or to another service that canaddress the problem. As the family beginsparticipating in the tailored activities, thecounselor maintains contact on a monthly basisthroughout the intervention year, both by phoneand in person. This contact enables the counselorto assess progress and provide continualreinforcement of key intervention concepts.

The asthma counselor at the El Rio Health Centerworked with the University of Arizona BiomedicalCenter to create intervention tools in Spanish.Group and individual sessions are conducted inboth English and Spanish. The project securedadditional funding from nonfederal sources topurchase medications and to pay for pulmonologistvisits, when indicated, for children with noinsurance. To help the children and their families,the El Rio staff developed a notebook to recordimportant telephone numbers and to keep trackof medication refills and times to use the peakflow meter. The notebook also includedinstructions on how to determine whether a childwith asthma symptoms should go to school.

The intervention was initially designed to includea role-playing component in the group trainingsessions. However, because the populationserved in this location was not comfortableengaging in role-playing, the counselor hadhelpers act out scenarios for the clients to watch.This enabled participating families to learn anddiscuss the role playing as a group and to benefitfrom this interaction without feeling pressured toparticipate. Children in the project are givenawards for responsible behavior rather than forattendance at meetings. A $20 gift certificate isawarded to children who take their medicationsand use their peak flow meters as prescribed bytheir individual asthma management plans.Parents report that their children have neverbeen so good about taking their medications.Children participating in the project have learned so much and enjoyed the program tosuch an extent that the asthma counselor has setup an extra “reunion” session for the children tosee their new friends and catch up on eachother’s progress.

The asthma counselor has worked with theschools and school nurses to allow children inthe project to use albuterol and a peak flowmeter and spacer at school when needed. Thecounselor also has provided school staff andnurses with asthma trigger information andcopies of the children’s asthma action plans.

The children and their parents have found theproject to be both valuable and helpful. The keyto this project’s success has been the ability ofthe project staff to make the learning environmentculturally sensitive, supportive, and interesting.


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A CDC project identified two asthma interventionprograms as science-based programs that are beingsuccessfully implemented at the community level tohelp children with asthma.

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S u c c e s s S t o r i e s

From Science to Intervention: DeterminingWhat Works for Asthma Across the country,people and organizations are searching for waysto prevent the rising rates of asthma in theircommunities. Asthma’s impact is especially felt inthe poorest inner-city areas. In 1999, CDCinitiated action to identify science-based asthmainterventions that could be replicated in a varietyof community settings and to share thisinformation at the state and local levels.CDC engaged the services of a contractor to (1)search the literature for research studies onasthma and (2) follow up with principalinvestigators to find out which studies actuallyhad been implemented in hospital, clinic, school,or other community-based settings. Thecontractor discovered that despite the fact thatmany successful asthma research studies havebeen conducted over the past decade, only twohave made a successful transition to animplemental intervention—Open Airways forSchools, prepared by the American LungAssociation, and Asthma Care Training for Kids, aprogram from the Allergy and AsthmaFoundation of America.

Finding out how few fully translatedinterventions were available was significantbecause it helped CDC better formulate itsprogram activities for fiscal year (FY) 2001 andbetter understand the complexities ofimplementing successful asthma interventions atthe community level. CDC used the knowledge itgained to contract for the translation of twomore research study models in FY 2001. CDC alsoprovided $941,000 to fund seven localorganizations, including hospitals and schools, to

implement Asthma Care Training for Kids andOpen Airways for Schools. CDC shared the resultsof this effort with the National Asthma Educationand Prevention Program, which is under theauspices of the National Heart, Lung, and BloodInstitute and is the lead federal agency forcoordinating efforts in asthma control. This year,CDC is updating its literature search, speaking toasthma experts across the country, and revisingits inclusion criteria in an effort to identify moreresearch models that may have been missed andto consider existing interventions which,although they may have not been based onresearch studies, warrant consideration on thebasis of their strong evaluation results. The workis challenging and illustrative of the complexitiesof asthma—a disease that cannot yet be curedbut can be controlled. CDC will continue itsefforts to identify and fund successfulinterventions that can make a measurabledifference in the lives of people with asthma.

Biomonitoring

CDC’s Report on Human Exposure toEnvironmental Chemicals Grabs NationalSpotlight In March 2001, CDC issued its

much anticipated National Report on HumanExposure to Environmental Chemicals, a rigorouslyscientific “state of the nation” examination oflevels of 27 environmental chemicals measuredin a representative sample of the U.S. civilianpopulation. From the ubiquitous metal, lead, tocertain everyday pesticides and a host ofplasticizers called phthalates, Americans got aglimpse of what they’re being exposed to in their

The key to the success ofthe Inner-City Asthma

Intervention project hasbeen the ability of the

project staff to make thelearning environment

culturally sensitive,supportive, and interesting.

environment. But the critical point is that thesechemicals were measured in people , not in air,water, soil, or food.

Some of the measurements told us that levels ofcertain chemicals, such as cotinine, a marker forexposure to tobacco smoke, had gone down by adramatic 75% since they were last measuredduring the period from 1988 through 1991;however, 24 of the chemicals (metals,organophosphate pesticides, and phthalates)listed in the Report had never been measuredbefore in the U.S. population. The Report alsoestablished reference ranges for these 24chemicals, documented the continued decline ofblood lead levels among children since levelswere measured during the period from 1991through 1994, provided a better assessment ofchildren’s and women’s exposure to mercury thanwas previously available, and helped to setpriorities for additional research on phthalates.

The Report provided information from theNational Health and Nutrition ExaminationSurvey (NHANES), CDC’s ongoing national surveyof the general U.S. population. NHANES is uniquein its ability to examine public health issues thatcan best be addressed through physical andlaboratory examinations of the U.S. population.This first Report was restricted to generalpopulation data from NHANES for 1999.

CDC scientists have been measuring chemicals inpeople for at least 25 years, both for national studies of population exposures and for studies

to examine exposures of specific populations. The work of these scientists has ranged fromassessing exposures that resulted in acutedisease or death to assessing those exposuresthat in the long term may cause cancer, birthdefects, neurologic deficits, or other chronicdiseases or conditions. CDC scientists alsoanticipated the need to measure levels in peopleexposed to unknown chemical agents that mightbe used by terrorists, and they have beenworking with state partners to increase thestates’ capacity to respond to these kindsof threats.

The success of the first Report is a direct resultof the exceptional dedication, scientific acumen,and visionary work of hundreds of people inthe laboratory doing their “ordinary” jobs toprotect public health every day—around theclock, if needed. These scientists have a keenand abiding interest in discovery and innovationand a determination and sense of urgency topersevere until they “get it right.” And they did.

Launched simultaneously through the NationalCenter for Environmental Health’s Web site andat a Washington, D.C., meeting with CDC’spartners, the Report received close scrutiny bypublic health advocates and industry andwidespread coverage and requests for interviewsby national print and broadcast media. Thiscoverage generated hundreds of requests forinformation from health care professionals andlay audiences worldwide.


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The National Report on Human Exposure toEnvironmental Chemicals revealed levels of 27chemicals measured in a sample of people in theUnited States.

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Public Health EmergencyResponse

Investment in the National PharmaceuticalStockpile Program Proves Invaluable AfterTerrorist Attacks Established by CDC 2 years

ago, the National Pharmaceutical Stockpile (NPS)Program evolved from CDC’s recognition of theneed for America to establish a lifesaving, highlymobile resource to respond to a national terroristattack. CDC’s investment in this resource provedto be invaluable on September 11, 2001. WhileAmerica was just beginning to comprehend thefull repercussions of the attacks in New York City

and Washington, D.C., and while all othercommercial aircraft were grounded, CDC’s NPSProgram staff were reporting to their emergencyoperations center (EOC) to arrange for airtransportation for Technical Assistance ResponseUnit (TARU) members and other CDC emergencypersonnel. Next, they immediately beganoperations to deploy to New York City the first

12-hour push package, a portable, fully stockedrepository of drugs, antidotes, and medical/surgical supplies designed to resupply stateand local public health agencies during aterrorism incident.

CDC had trained TARU members to accompanypush packages and to be prepared to start,operate, and repair the packages’ counting/packaging machinery as well as provide detailedconsultation and technical assistance to localhealth and emergency personnel. CDC also hadsecured specialized cargo containers for the pushpackages and had updated methods used forrepackaging and distribution. These measureswere soon to pay off for the American people.

The EOC was fully staffed and functional at 9:00AM, within 15 minutes after the report of the firstplane crash into the World Trade Center; therequest from New York State and local officials fora push package came in at 2:43 PM. By that time,NPS Program staff had contacted all theircommercial and government partners and hadcoordinated the logistics for moving the pushpackage from its undisclosed location. Within30 minutes, a push package was deployed forthe first time in history. The push package, whichcan be transported by either air or ground, wastransported by ground on September 11 and hadtook only 7 hours from the time of the request toreach its destination, exceeding expectations forresponse time.

By 6:30 PM, members of TARU were on theground in New York City, providing assistance to

National Pharmaceutical Stockpile Program staff loading cargo into wide-body aircraft to respond to the terrorist attacks.

the mayor’s office. When the push packagearrived at 10:00 PM, members of TARU met it and helped public health and emergencypersonnel rapidly procure, transport, and stage NPS assets. NPS Program staff also arranged for rapid delivery of more than 60 loads of vendor-managed inventory (VMI) to New York City. VMI packages, which contain drugs and medical supplies like push packagesbut which can be tailored to a specific situation,began arriving in New York City within 12 hoursof the official request.

During the crisis, the NPS Program was responsiblefor the delivery of thousands of pounds of drugs, supplies, and protective equipment forvictims and rescue workers. Only 2 years old, the NPS Program had been tested in a real-lifeterrorist attack. By all accounts, it passed withflying colors.


High-Intensity Targeted ScreeningExemplifies Effective CollaborationBetween CDC, Communities, and Key

Organizations CDC has made a commitment toeliminate childhood lead poisoning in theUnited States by 2010. Reducing blood leadlevels (BLLs) to less than 10 µg/dL of blood is atall order, requiring CDC to rapidly identify andfollow up on large numbers of high-risk children.How can such a feat be accomplished? One wayis by teaching states how to conduct high-

intensity targeted screening (HITS) on a door-to-door basis. CDC’s Lead Poisoning PreventionBranch completed the first HITS project in twoinner-city communities in Chicago in November

2001. CDC’s environmental health laboratorytrained 20 teams (comprising 100 ChicagoDepartment of Public Health staff members whoworked in lead poisoning prevention) in theproper way to collect and analyze blood leadsamples. CDC also assembled sample kits foreach of the 20 teams and provided technicalassistance and advice in the field. This first HITSproject was a collaborative effort among CDC, theChicago Department of Public Health, the IllinoisDepartment of Public Health, the Department ofHousing and Urban Development, the U.S.


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One of the 581 inner-city Chicago children whose blood lead levelswere measured in CDC’s High-Intensity Targeted Screening project.The project was a collaborative effort among CDC and other federal,state, and local agencies.

Established by CDC 2 yearsago, the National

Pharmaceutical Stockpileevolved from the need for

America to establish alifesaving, highly mobileresource to respond to anational terrorist attack.

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Environmental Protection Agency, and theCenters for Medicare and Medicaid Services.

CDC selected the two communities—Austin andEnglewood—for two reasons: (1) their rates ofelevated BLLs were among the highest in the nation and (2) the Chicago Lead Poisoning Prevention Program (CLPPP) wanted todetermine whether it was identifying andscreening all high-risk children.

During the 3-week project, CDC assisted withstudy design, provided laboratory support, andcollected and analyzed data. Americorp workers,community members, staff from the ChicagoDepartment of Public Health, and graduatestudents from Emory University’s Rollins Schoolof Public Health conducted door-to-doorscreening. The Westside Health Authority and theEnglewood Neighborhood Health Centerprovided the base of operations from whichproject participants worked.

Blood samples were collected from 581 children12 to 71 months of age. The families of the testedchildren received educational materials, andwhen children were identified with elevated BLLs,the families were offered appropriate medicalmanagement and a home investigation toidentify all possible sources of lead exposure.

The director for CLPPP declared that the ChicagoHITS project was a success because it had forgedpartnerships and stimulated community interestin eliminating lead poisoning among children.CLPPP plans to use HITS data to improvescreening plans, better direct resources, and

monitor progress toward eliminating childhoodlead poisoning. At least two more HITS projectsare planned elsewhere in the nation in 2002.The methods developed by the Chicago HITSproject can be replicated by other communitiesthat want to collect representative baselinedata in their efforts to eliminate childhoodlead poisoning.

Environmental Health Services

Protocol for Assessing CommunityExcellence in Environmental Health GoesInternational With a precedent-setting

project in South America, CDC debuted in aninternational setting the successful Protocol forAssessing Community Excellence in EnvironmentalHealth (PACE-EH). PACE-EH was developed by theNational Association of County and City HealthOfficials with funding from CDC. Through theCARE-CDC Health Initiative, both agencies helpedbuild local capacity in public and private sectorsto conduct community-based environmentalhealth assessments in two Peruvian communities.The project collaborators used PACE-EH inplanning and conducting the environmentalhealth assessment activities, making the projectthe first implementation of PACE-EH outside theUnited States. Because of the success of theproject and the development of a communityhealth assessment capability, the U.S. Agency forInternational Development decided to fund the$2.5-million, 3-year project for CARE Peru toestablish environmental health capacity in threeadditional communities. CDC is now assistingthese communities in (1) characterizing and

CDC and CARE are teaching communities in Peru touse the Protocol for Assessing Community Excellence inEnvironmental Health to address public health issuessuch as drinking water supply. Here, children drawwater from a public well while staffers discuss theissues.

evaluating local health conditions and concerns,(2) identifying their environmental health risksand hazards, (3) collecting meaningfulenvironmental data to establish a monitoringsystem for environmental health-related issues,and (4) setting priorities for actions to addressenvironmental health problems and prepareeffective interventions. CDC determined thatincluding community residents throughout theassessment process aided their understanding ofcomplex environmental health issues. Thisincreased understanding has enabled thecommunities to develop practical solutions toimprove their environmental health conditions.

Genomics

Informed Consent Document Is Developedfor Participants in Population-Based StudiesResearch involving genetics must be

conducted ethically and must include theinformed consent of study participants. However,little guidance has been available for population-based studies of common gene variants with lowto moderate individual disease risks.Recommendations developed for family-basedresearch are not well suited for most population-based studies because the recommendationsgenerally do not distinguish clinically relevantinformation from epidemiologic data, which aremeaningful only at the population level and

involve few physical, psychological, or social risksfor individual participants. In response to this dilemma, CDC worked with a multidisciplinarygroup of experts and developed content andprocess guidelines for informed consent forpopulation-based genetic research studies. Theguidelines address several important issues. Theconsent document must include informationthat outlines why the study is being done, whatis involved in the study, how informationcollected about research subjects will be keptconfidential, and what the risks and benefitsmight be for study participants. The consentdocument must clearly state what is to be donewith any remaining biologic samples when thestudy is completed. In addition, some geneticstudies may have the potential to result in aproduct with commercial value. When thispossibility exists, it should be disclosed alongwith a statement about whether participantswould share in any profits.

An article about these guidelines for informedconsent for population-based genetics researchwas published in the November 14, 2001, issue ofJAMA. This new informed consent document andsupplemental brochure are intended to helppeople make informed decisions aboutparticipating in genetic studies and, in turn, tohelp bridge the gap between gene discovery andthe ability to use genetic information to improvehealth and prevent disease.


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Information provided to participants in geneticsstudies must include information about (1) thestudy, (2) the measures being taken to protectparticipants’ privacy, and (3) the risks and benefits.

Asthma

Asthma Death Rates Increase AmongElderly White Females Although deathrates for asthma increased between 1979

and 1997, analyses to determine thedemographic subgroups most affected by

the increase have not been conducted. Inresponse to this need, CDC used

Underlying Cause of Death files for1979 through 1995 to calculateannual and age-, sex-, and race-specific death rates. The resultsshowed that deaths from asthmaincreased from 2,603 in 1979 to5,645 in 1995. In the single variableanalysis, rates of asthma mortalityincreased more in people olderthan 65 years of age than in

younger people, in women morethan in men, and in African-American

women more than in white women.When considering age, sex, and race

simultaneously, the single subgroup thataccounted most for the increase in asthma

mortality was white women aged 65 years andolder. Subgroup characteristics are important

considerations when interventions are planned andoutcomes are assessed.

Moorman JE, Mannino DM. Increasing U.S. asthma mortality rates: who isreally dying? J Asthma 2001;38(1):65–71.

Key Research Findings

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Olympic Games Provide Insight on Traffic, AirQuality, and Asthma Control Although ozoneand particulate pollution are associated withtransient increases in asthma morbidity, theimpact of citywide transportation changes on airquality and childhood asthma has not beenstudied. The alternative transportation strategyimplemented in Atlanta during the 1996 Olympicgames provided an opportunity to conduct sucha study. In this study, CDC compared the 17 daysduring which the Olympics took place with the4 weeks preceding and following the games.During the Olympics, numbers of acute care visitsfor asthma decreased 44% and numbers ofemergency room visits decreased 11%; however,numbers of nonasthma-related acute medicalvisits did not change. Ozone, particulates, andcarbon monoxide levels dropped 28%, 16%, and18.5%, respectively. One-hour peak AM weekdaytraffic counts dropped 22.5%. Traffic counts weresignificantly correlated with peak ozone levels.These findings suggest that decreasingautomobile congestion, especially during thecritical morning rush-hour period, can improveair quality and have a substantial impact on theburden of asthma among our cities’ children.Thus, the study provided important experimentalevidence that traffic patterns, air quality, andrespiratory health are causally linked.

Friedman MS, Powell KE, Hutwagner L, GrahamLM, Teague WG. Impact of changes intransportation and commuting behaviors duringthe 1996 summer Olympic games in Atlanta on air quality and childhood asthma. JAMA2001;285:897–905.

Medical Examiners’ Investigation Sheds Lighton Elevated Asthma Mortality Rate The asthmadeath rate for New York City is twice the rate forthe entire country. To better understand thecircumstances surrounding the asthma deaths,CDC abstracted medical examiner (ME) files forasthma-related deaths in New York City for 1995through 1997. Investigators’ field reports wereavailable for 96% of the ME cases, as werepathology reports for 63% of the cases,toxicology reports for 68% of the cases, andmicroscopic examination reports for 56% of thecases. Forty-four percent of deaths occurredwithout medical attention. Pathology findingswere consistent with death caused by acuteasthma. Drugs with abuse potential weredetected in 38% of people for whom toxicologyreports were available. These detailed analyses ofME cases show that a substantial number ofasthma-related deaths occurred without medicalattention and that use of drugs with abusepotential may be a risk factor for asthma-relateddeath in New York City. CDC will conduct moredetailed analysis of the study’s data to identifyaspects of severe asthma exacerbations that haveintervention potential and that may be used toprevent deaths from asthma in the future.

Moorman JE, Mannino DM, Redd SC, Matte T, GargR, Leighton J, et al. Asthma mortality in New YorkCity: medical examiner’s data. American ThoracicSociety meeting, San Francisco, May 2001.

A CDC study of New York City medical examinerfiles showed that 44% percent of asthma deathsoccurred without medical attention. Another CDCstudy of asthma deaths revealed that asthma deathrates increased more in elderly white women from1979 through 1995 than in any other group.

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K e y R e s e a r c h F i n d i n g s

Asthma Hospitalizations More Prevalent inNortheast United States Hospitalization ratesfor asthma in the Northeast have been higherthan in other regions for the past 20 years. Toassess whether these higher rates in the Northeastreflect differences in asthma presentation orseverity or general differences in hospitalizationpractices, CDC examined regional differences inasthma hospitalizations from 1988 through 1996using data from the National Hospital DischargeSurvey. From 1988 through 1996, the age-adjusted rate of hospitalizations for asthma as the first-listed diagnosis increased in the Northeastbut declined in other regions; however, the age-adjusted rate for all hospitalizations declined inall regions. These results indicate that the higherrates of hospitalization for asthma observed forthe Northeast are not related to generalhospitalization patterns and thus suggest thatasthma in that region may present more severely.Further studies are needed to verify whetherasthma indeed does present more severely in theNortheast, and if so, why.

Homa DM, Mannino DM, Redd SC. Regionaldifferences in hospitalizations for asthma inthe United States, 1988–1996. J Asthma. Inpress 2002.

Asthma Types Can Be Determined fromNHANES Data CDC used NHANES III data tocategorize children aged 6 through 16 years(n = 5,683) into three distinct a priori-definedasthma types: “allergic,” representing childrenwith asthma who have a positive skin test resultto one or more of 10 allergens; “ nonallergic,”representing children who have a negative skin

test result to all 10 allergens; and “resolved,”representing children who have a history ofasthma but no current symptoms. Among allsurveyed children aged 6 through 16 years, 6.5%had allergic asthma, 1.5% had nonallergicasthma, and 3.4% had resolved asthma. Lungfunction was measured as the ratio of forcedexpiratory volume over 1 second to forced vitalcapacity (FEV1/FVC); people with an FEV1/FVCratio less than 80% were considered to havediminished lung function. A greater proportion ofchildren with nonallergic asthma had diminishedlung function (48% compared with 35% forchildren with allergic asthma); 39% of childrenwith resolved asthma had an FEV1/FVC ratio lessthan 80%. Children with allergic asthma andchildren with resolved asthma had similar lungfunction results. This analysis, which demonstratesthat distinct asthma types can be identified fromepidemiologic data, may help researchers betterunderstand the disease.

Homa DM, Mannino DM, Redd SC.Characterization of asthma types for childrenaged 6-16 years from NHANES III. Abstractsubmitted for the American Thoracic SocietyInternational Meeting, May 17–22, 2002, Atlanta, GA.

Biomonitoring

Relation Examined Between PrematureBirths and Exposure to ChlorinatedPesticides In 1999, 11.8% of all babies in

the United States were born prematurely. Toexamine the relation between premature birth


56

and exposure to chlorinated pesticides, particularlyto DDT and its metabolite DDE, CDC collaboratedwith the National Institute of EnvironmentalHealth Sciences (NIEHS) to conduct this study.Laboratory scientists measured concentrations ofDDE in stored serum collected from pregnantwomen who gave birth during the period 1959through1966, when DDT was heavily used in theUnited States. Of the 2,380 babies born to thesewomen, 361 were born prematurely. Statisticalanalyses revealed that the greater the level ofDDE in a mother’s blood, the greater the risk for apreterm delivery (i.e., less than 37 weeks’gestation). DDT is no longer used in the UnitedStates; however, in the 25 countries where it isused to control the mosquitoes that causemalaria, DDE serum levels can greatly exceedthose found in the NIEHS/CDC study.

Longnecker MP, Klebanoff MA, Zhou H, Brock JW.Association between maternal serumconcentration of the DDT metabolite DDE andpreterm and small-for-gestational age babies atbirth. Lancet 2001;358:110–4.

Children Are at Greater Risk for Exposure toOrganophosphate Pesticides Protectingchildren from exposure to pesticides is a keyenvironmental health concern. CDC collaboratedon two important studies assessing exposure toorganophosphate (OP) pesticides. One study,done in collaboration with the University ofWashington Children’s Environmental HealthCenter, was conducted in an agriculturalcommunity in the state of Washington. Investigatorsmeasured levels of chlorpyrifos and parathionamong children aged 6 years or younger. Levels

of these neurotoxic agents were measured inhouse dust and surface-wipe samples, and theirmetabolites were measured in the children’surine. Study results showed that house dust inthe homes of people who worked in agricultureor who lived near pesticide-treated farmland hadhigher levels of these pesticides than did thehouse dust in other homes in the same communitybut that most study children had very low ornondetectable levels of the metabolites of theparent compound in their urine.

In the second study, done in collaboration withthe Columbia University Center for Children’sEnvironmental Health, CDC scientists determinedbackground levels, detection limits, and stabilityof six OP pesticide metabolites in the meconiumof newborns. Scientists think that measuringpesticides in meconium may yield informationabout long-term exposure to these pesticides;existing biomarkers reflect only short-termexposure. All but two of the metabolites weredetected in the meconium samples. Preliminaryresults thus indicate that, in general, pesticides docross the placental barrier. More research isneeded to evaluate the dose-response relationand to determine the time frame of exposurerepresented by the presence of the metabolitesin meconium.

The work represented by these studies isparticularly relevant to the 1996 Food QualityProtection Act, which requires the federalgovernment to take special steps to protectchildren by increasing its scrutiny of children’sexposure to pesticides. Two key provisions of theAct are the requirements that an additional

Health effects of exposure to pesticides were examined in three CDC studies: one on prematurebirths and pesticide metabolites, one on pesticidemetabolites found in children’s bodies, and one onpesticide metabolites found in the meconium ofnewborns.

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tenfold margin of safety be applied in settingtolerances for pesticide use and that aggregateand cumulative exposures be considered toensure that infants and children are adequatelyprotected from exposure through chemicalresidues or other sources.

Fenske RA, Lu C, Barr DB, Needham LL. Children’sexposure to chlorpyrifos and parathion in anagricultural community in central Washingtonstate. Environ Health Perspect 2002. In press.

Whyatt RM, Barr DB. Measurement oforganophosphate metabolites in postpartummeconium as a potential biomarker of prenatalexposure: a validation study. Environ HealthPerspect 2001;109:417–20.

Additional Health Consequences of Exposureto Dioxin Found During fiscal year 2001, CDCscientists continued their efforts to link exposureto 2,3,7,8-tetrachlorodibenzo-p-dioxin to adversehealth effects in people. Studies completed in2001 show a statistically significant associationbetween levels of dioxin and breast canceramong women who were exposed to dioxin aftera major explosion in a chemical plant in Seveso,Italy, in 1976. Dioxin persists for a long time in thebody, and CDC’s environmental health laboratoryhas the ability to measure dioxin exposure inhuman samples many years after that exposurehas occurred. In another study, CDC, incollaboration with the Department of VeteransAffairs, measured dioxin concentrations inveterans who served in Vietnam in the U.S.Army’s Chemical Corps and sprayed AgentOrange, a dioxin-containing defoliant, from

backpacks. CDC determined that the dioxinconcentrations found in recently collected serumfrom veterans who served in Vietnam more than30 years ago can be used to identify exposurevariables for a health survey of exposure tophenoxyherbicides, which contain dioxin. TheDepartment of Veterans Affairs will now determinewhether to conduct the health survey.

Warner M, Mocarelli P, Eskenazi B, Samuels S,Gerthoux PM, Needham LL, et al. Serum dioxinconcentrations and breast cancer risk in theSeveso Women’s Health Study. Environ HealthPerspect. In press 2002.

Kang HK, Dalager NA, Needham LL, Patterson JrDG, Matanoski GM, Kanchanaraksa S, et al. U.S.Army Chemical Corps Vietnam veterans’ healthstudy: preliminary results. Chemosphere2001;43:943–9.

CDC Collaborates with Denmark to Study InUtero Exposure to Polychlorinated Biphenylsand Mercury Several environmental pollutantsare neurotoxic and may cause adversedevelopmental effects after in utero exposure. Inthe early 1990s, children born in the Faroe Islandsof Denmark were thought to have beenexcessively exposed to polychlorinated biphenyls(PCBs). CDC, working with Danish investigators,analyzed PCBs and chlorinated hydrocarbonpesticides in the umbilical cords of thesechildren. As part of this continuing collaboration,CDC is now assessing fetal exposures to PCBs andmercury and their relation to 17 neuropsychologicaloutcomes that are determined when childrenreach 7 years of age. One recent finding was that

A soldier sprays Agent Orange, a dioxin-containingdefoliant, in Vietnam. In 2001, CDC (1) measureddioxin concentrations in serum collected recentlyfrom Vietnam veterans who sprayed Agent Orangefrom backpacks and (2) studied women who wereexposed to dioxin after a chemical plant explosionin Italy.


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PCB exposure alone did not account for adversehealth effects seen during the extensiveneurobehavioral and cognitive testing of thesechildren. However, PCB-associated deficits werefound in those children with the highest levels ofexposure to mercury. Additional studies areongoing to help resolve this important issue.

Grandjean P, Wiehe P, Burse VW, Needham LL,Storr-Hansen E, Heinzow B, et al. Neurobehavioraldeficits associated with PCBs in 7-year-oldchildren prenatally exposed to seafoodneurotoxicants. Neurotoxicol Teratol2001;23:305–17.

Personal Activities Identified that Lead toExposure to Volatile Organic Compounds Incollaboration with the Agency for ToxicSubstances and Disease Registry, CDC studiedblood levels of volatile organic compounds(VOCs) and questionnaire responses ofparticipants in the National Health and NutritionExamination Survey (NHANES) III (1988–1994) todetermine whether certain activities wereassociated with increased VOC levels. VOCs havebeen linked to cancer and neurological and otherhealth effects in animals and people.

This study showed statistically significantrelations between lifetime pack-years ofcigarettes smoked and internal-dose levels ofbenzene, toluene, and styrene. In addition, bloodlevels of acetone and 2-butanone increased withalcohol consumption. The study also found thatusing a well as a water source resulted in astatistically significant lower likelihood of havingelevated levels of blood bromodichloromethane

(a disinfection by-product). Study results indicatethe need for further investigation of activitiesthat expose people to VOCs and how to minimizethis exposure.

Churchill JE, Ashley DL, Kaye WE. Recent chemicalexposures and blood volatile organic compoundlevels in a large population-based sample. ArchEnviron Health 2001;56(2):157–66.


Blood Lead Levels in Children DeclineNationally, but Problems Persist LocallyLead poisoning can cause learning

disabilities; behavioral problems; and at very highlevels, seizures, coma, and even death. Blood leadlevels (BLLs) equal to or greater than 10 µg/dL areconsidered elevated and warrant action toreduce exposure to lead. CDC responded to thiscall for action by analyzing data from theNational Health and Nutrition ExaminationSurvey (NHANES) 1999, NHANES III Phase 2, andthe Childhood Blood Lead Surveillance (CBLS)program. The purpose of this endeavor was todetermine childhood BLLs on the national, state,and local levels from 1996 to 1999.

NHANES, a continuous survey of the healthand nutritional status of the U.S. civilian,noninstitutionalized population aged 6 monthsand older, provided data on average BLLs andpercentiles but not on the prevalence of elevatedBLLs. CDC analyzed CBLS data, which consisted of

CDC's study of blood levels of volatile organiccompounds (VOCs) indicated that exposure to VOCscan be increased by personal habits such as smokingor drinking alcohol or decreased by ordinary activitiessuch as using a well for a water source instead oftap water.

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data that 19 states had reported to CDC, toidentify the proportion of children with elevatedBLLs among those tested from 1996 to 1999.

Children aged 1 through 5 years who had bloodlead tests in NHANES in 1999 had lower leadlevels than children tested in NHANES III Phase 2(1991 through 1994). The geometric mean (theantilog of the mean of the logs) BLL, which isused for more rigorous population samples suchas NHANES, decreased from 2.7 µg/dL in NHANESIII Phase 2 to 2.0 µg/dL in NHANES 1999. CBLSdata showed that the proportion of childrentested with BLLs > 10 µg/dL decreased from10.5% in 1996 to 7.6% in 1998 in the 19 statesproviding data. Within states, the proportion ofchildren with elevated BLLs in counties with atleast 200 children tested also varied considerably.Across all 19 states, the county-specificproportions of children with elevated BLLsranged from 0.5% to 27.3%, indicating aconcentrated proportion of elevated BLLs inspecific populations or geographic areas.

The findings indicate that, despite the decreasesin geometric mean BLL among children, theproblem remains concentrated on a local level.These findings indicate the need for surveillanceefforts to target screening activities tocommunities at highest risk.

CDC. Blood lead levels in young children—UnitedStates and selected states, 1996–1999. MMWR2000;49(50):1133–7.

Geographic Information System Data Used toGuide Lead Screening Strategies Childrenliving in older houses, which may contain leadedpaint, are at greatest risk for lead poisoning;consequently, CDC recommends screening thesechildren for lead. Geographic information system(GIS) technology, which has the capability to mapareas with older housing, has helped state andlocal health departments, including JeffersonCounty’s well-established Kentucky ChildhoodLead Poisoning Prevention Program, assess andimprove their screening efforts. This evaluationstudy focused on children aged 6 to 35 monthsand defined children at risk as those living in ahome built before 1950 or in an area where atleast 27% of the homes were built before 1950.The program combined birth record data, leadscreening data, and tax assessor data to identifychildren at risk for lead poisoning and todetermine the proportion of at-risk children whowere being screened.

Findings showed that 50% of the children livingin housing built before 1950 were screened forlead exposure in 1996 and 1997. Seventy-ninehousing units were identified as posing anextraordinary risk to child residents, as evidencedby the fact that these units accounted for 35% ofthe instances in which more than one childresident had an elevated BLL equal to or greaterthan 20 µg/dL. The GIS data analysis revealed thatsubstantial numbers of at-risk childrenthroughout Jefferson County, including thoseliving in targeted screening areas, were not beingtested for lead exposure. This studydemonstrated how GIS can be useful to health

Elevated blood levels are found more often in children who live in housing built before 1950, whenlead-based paint was still being used.


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departments in planning lead exposure screeningstrategies and in measuring program performance.

Reissman DB, Staley F, Curtis GB, Kaufmann RB.Use of geographic information systemtechnology to aid health department decisionmaking about childhood lead poisoningprevention activities. Environ Health Perspect2001;109(1):89–94.

CDC Develops Recommendations to Ensurethat Children Enrolled in Medicaid UndergoBlood Lead Screening Because children who livein low-income families are at higher risk for leadpoisoning than other children, federal lawrequires states to screen children who areenrolled in Medicaid for elevated BLLs throughthe Early and Periodic Screening, Diagnosis, andTreatment Program. However, national datacollected from NHANES III (1991 through1994)show that only 19% of children aged 1 to 5 yearsand 21% of children aged 1 through 2 years whowere enrolled in Medicaid had received a bloodlead test. In addition, the study showed that most(83%) of the U.S. children aged 1 to 5 years whohad BLLs > 20 µg/dL were enrolled in Medicaid.The low screening and high prevalence ratesamong children enrolled in Medicaid promptedthe Advisory Committee on Childhood LeadPoisoning Prevention to developrecommendations to ensure blood leadscreening and follow-up care for young childrenenrolled in Medicaid. In December 2000, CDCpublished recommendations to health careproviders, states, and other agencies thatadminister Medicaid programs. These

recommendations, if adopted by states, will helpimprove the delivery of lead-related services toyoung children.

CDC. Recommendations for blood lead screeningof young children enrolled in Medicaid: targetinga group at high risk. MMWR 2000;49 (RR-14).

Scientists Assess Blood Lead Levels ofChildren in Torreón, Mexico In March 2001,Mexico’s Environmental Protection Agency askedCDC to conduct an investigation to determinewhether the children of Torreón were beingexposed to hazardous levels of lead. This smalltown is home to a metal-processing plant (leadsmelter) that is the largest in Latin America andthe fourth largest in the world. Scientists fromCDC’s lead program and environmental healthlaboratory collaborated on the study. Theymeasured the blood lead levels (BLLs) of children1 to 6 years of age living in Torreón, particularlythose children living in the area around thesmelter, and assessed risk factors for leadexposure among these children. The strongestpredictor of elevated BLLs was proximity to thesmelter. Dust and soil lead levels were alsohighest closer to the smelter.

The geometric mean BLL of children in this studywas 8.3 micrograms per deciliter (µg/dL) for thesmelter area and 5.5 µg/dL for the cluster-surveyarea. (CDC has defined an elevated BLL as > 10µg/dL.) The percentage of children with BLLs >10 µg/dL was 33.0% for the smelter area and16.7% for the cluster-survey area. These values

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are considerably higher than the geometric meanfound among U.S. children, which in the early 1990s was 2.7 µg/dL for children 1 through 5years of age. The percentage of children in theU.S. population with BLLs > 10 µg/dL is 4.4%. Anoteworthy point is that although mean BLLsand the percentage of children with elevatedBLLs found in this study were higher than thoselevels observed in the United States, they werelower than those observed in previous studies ofchildren in other communities (such as in BritishColumbia and Quebec, Canada) where smeltingoperations had yet to undergo remediation.

Letters were sent to households to informparents of the results of their children’s tests andof the environmental sampling. In these letters,parents whose children had BLLs > 20 µg/dL

were encouraged to seek confirmatory bloodtests; parents of children with levels > 45 µg/dLwere asked to take their children to their healthcare provider for immediate follow-up. The costs ofany needed medical treatment are to be coveredby a trust set up by the metal-processing company.

CDC recommended that the community not onlycontinue to monitor lead emissions and dust andsoil levels in the areas around the processingplant but also target educational interventions toreduce lead exposure in Torreón children.

CDC. Blood lead levels and risk factors for leadpoisoning among children in Torreón, Coahuila,Mexico. Final report. Atlanta (GA): Dept. of Healthand Human Services (US), Centers for DiseaseControl and Prevention; 2001.

Genomics

CDC Publishes First-Ever NationallyRepresentative Prevalence Data forHemochromatosis Genes Scientists

have taken a big step forward in helping toanswer questions about hereditaryhemochromatosis, the most common geneticdisease in the United States. This genetic diseasecauses people to absorb excess amounts of ironfrom their diet that then accumulates in organssuch as the heart, liver, and kidneys. This “ironoverload” causes diseases such as cirrhosis andheart failure and in some cases, death.However, hemochromatosis can be preventedif detected early.

Children living near a metal-processing plant in Torreon, Mexico, werestudied by CDC to determine their blood lead levels. Blood lead levelsin these children were higher than in U.S. children but lower than inchildren studied in other communities where smelting operationshad not yet been remediated.

Hemochromatosis, an inherited disorder that causespeople to absorb too much iron from their diet, isthe most common genetic disease in the UnitedStates. CDC studied the prevalence in the white U.S.population of two gene mutations that, if inheritedtogether, predispose a person to hemochromatosis.


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CDC published the first population-basedestimates of gene variants that are associatedwith hereditary hemochromatosis in the whiteU.S. population. These rare gene variants thatpredispose people to hereditary hemochromatosisare called C28Y and H63D. People in the whitepopulation who inherit two copies of one ofthese variants, or one of each of the variantsrather than the normal form of the gene, will besusceptible to iron overload. In the United States,5.4% of the population has at least one copy ofthe C28Y variant, and 13.5 % has at least onecopy of the H63D variant.

This study revealed that other gene variants mustbe found to account for the disease amongAfrican-American and Hispanic populations.Information about the prevalence of genevariants associated with the disease and thepenetrance of these variants is critical for makingpublic health decisions about genetic screeningfor this disease.

Steinberg KK, Cogswell ME, Chang JC, Caudill SP,McQuillan GM, Bowman BA, et al. The prevalenceof C28Y and H63D mutations to thehemochromatosis (HFE) gene in the UnitedStates. JAMA 2001;285(17):2216–22.

Public Health Agencies Recognize Need toIncorporate Genetic Discoveries into CoreActivities Genetic predisposition influences theonset and severity of most diseases of publichealth importance. Fortunately, as technologyadvances, so does our ability to assess humangenetic predisposition for many diseases.Therefore, state public health agencies need to

incorporate new developments in genetics anddisease prevention into their core activities ofassessment, policy development, and assurance.To assess this process of incorporating newdevelopments in genetics and diseaseprevention, CDC’s Office of Genetics and DiseasePrevention collaborated with the Council of Stateand Territorial Epidemiologists to survey statesabout projects and concerns pertaining togenetics and public health activities. Staterespondents were the health officer, the maternaland child health/genetics program director, thechronic disease program director, and thelaboratory director.

Thirty-eight (76%) state health departmentsresponded to the survey. According to theresponses, ongoing genetics activities in thestates and corresponding percentages wereassurance (82%), assessment (17%), and policydevelopment (2%). However, state health officersindicated that future genetics activities would bedistributed differently: assurance, 41%; assessment,36%; and policy development, 23%. Plans are forfuture assurance activities to be largelyeducational. Respondents reported that topics ofinterest and recently initiated activities ingenetics were primarily assessment functions.Funding was the respondents’ greatest concern,followed by lack of proven disease preventionmeasures and outcomes data.

Survey results show that state healthdepartments recognize a need to realign theiractivities to meet future developments ingenetics. Potential barriers are lack of adequateresources, proven disease prevention measures,

In collaboration with the Council of State andTerritorial Epidemiologists, CDC's Office of Geneticsand Disease Prevention surveyed state public healthofficials about their concerns and projects related togenetics.

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and outcomes data. Public health agenciesneed strategic planning to take advantage ofthe opportunities associated with thedevelopment and implementation of genetictests and procedures.

Piper MA, Lindenmayer JM, Lengerich EJ, Pass KA,Brown WG, Crowder WB, et al. The role of statepublic health agencies in genetics and diseaseprevention: results of a national survey. PublicHealth Rep 2001;116:22–31.

International Health

Measles Is a Significant Contributor toMortality in Ethiopian Famine Whileassisting the United Nations Children’s

Fund (UNICEF) with coordinating a famine reliefeffort in Ethiopia, CDC staff and the United StatesAgency for International Development’s Office ofForeign Disaster Assistance jointly assessedfamine-affected areas. A survey was designedand conducted to enable determinations to bemade about nutrition and retrospective mortalityin the Gode district, the epicenter of the famine.In addition, a database was designed thatcollated information from nutrition surveysconducted by all UN agencies and nongovernmentalorganizations (NGOs) in famine-affected areas ofEthiopia. CDC’s activities helped standardizesurvey methods and improve the standards offeeding programs operated by UN agencies andNGOs. The Gode survey highlighted the region’songoing nutritional crisis and the fact thatmeasles contributed to mortality. The findingsillustrated the need to extend measles

vaccination coverage to children between 5 and14 years of age. The CDC article published in theJournal of the American Medical Association as aresult of this research was one of the first todemonstrate epidemiologically the potentialnegative effects of a humanitarian response thatis not based on sound knowledge of publichealth principles. The article received widespreadcoverage among the media and led several UNagencies to review their policies and practices.UNICEF has since asked CDC to collaborate withColumbia and Tufts universities to establishworldwide training for UNICEF staff in emergencyresponse. Furthermore, UNICEF is prioritizingmeasles vaccination as a major activity. As a resultof the CDC article, the target age group formeasles vaccination is now widely accepted asbeing up to 15 years.

Salama P, Assefa F, Talley L, Spiegel P, van der VeenA, Gotway CA. Malnutrition, measles, mortality,and the humanitarian response during a faminein Ethiopia. JAMA 2001;286:563–71.

Surveillance for Human ImmunodeficiencyVirus Lacking in Complex EmergenciesResearch by CDC has shown that despite recentsuccess in preventing human immunodeficiencyvirus (HIV) infection in stable populations inselected developing countries, internallydisplaced persons and refugees have not beensystematically included in HIV surveillancesystems or consequently in prevention activities.Standard surveillance systems that rely onfunctioning health services may not provideuseful data in many complex emergency settings.However, second-generation surveillance


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methods—such as cross-sectional, population-based surveys—can provide rapid information onHIV, sexually transmitted infections (STIs), andsexual behavior, though the risks of stigmatizationand breaches of confidentiality presented bysecond-generation methods must be recognized.On the basis of CDC’s research, which waspublished in the journal AIDS, surveillance isrequired to define the high-risk groups and totarget interventions. Such surveillance willultimately decrease HIV and STI transmissionwithin countries facing complex emergencies aswell as facilitate regional control of HIV epidemics.

Salama P, Dondero T. HIV surveillance in complexemergencies. AIDS 2001;15 Suppl 3:S4–S12.

Improving the Diagnosis,Treatment, and Prevention ofChronic Diseases

Tobacco-Related Issues

Latino Tobacco Workers’ Risk of Getting GreenTobacco Sickness Studied Dermal exposure tonicotine by tobacco workers is known to beassociated with a form of nicotine poisoningcalled green tobacco sickness (GTS). In recentyears, tobacco work has been performed mainlyby migrant workers, almost all Latino, who havelittle experience with tobacco production and areoften unaware of their risk of developing GTS.This study examined a cohort of 182 workers inNorth Carolina during the summer of 1999.

Repeated salivary cotinine measurementsobtained over the course of the seasondemonstrated that these workers experiencedsubstantial work-related exposure to nicotine.The analyses indicated that exposures variedgreatly by activities, with “priming” or harvestingof tobacco associated with the greatestexposure risk. The analyses also helped identifywork behaviors that might mediate the riskfor exposure.

These results are being used to developeducational materials for workers to help themavoid exposure and thus decrease their risk ofdeveloping GTS. In addition, a follow-up case-control study is in progress of workers who didand who did not develop GTS.

Quandt SA, Arcury TA, Preisser JS, Bernert JT,Norton D. Environmental and behavioralpredictors of salivary cotinine in Latino tobaccoworkers. J Occup Environ Med 2001;43:844–52.

Newborn Screening

Errors Prevented in Assaying Blood-SpotSpecimens Substances known asacylcarnitines are organic- and fatty-acid

metabolites, and five of these metabolites are keyto diagnosing several disorders of fatty- andorganic-acid metabolism during newbornscreening using routine blood-spot specimens.Preliminary results with blood spots demonstrateexcellent linearity for each of the fiveacylcarnitines. However, during proficiencytesting (PT) conducted on assays performed by

Handling tobacco---like smoking it---can make yousick, as CDC found in a study of Latino tobaccoworkers.

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laboratories that participate in CDC’s PT program,CDC scientists observed an extremely unusualresult for the metabolite octanoylcarnitine: therecovery was significantly lower than that forother acylcarnitines. To account for thisdiscrepancy and prevent it from recurring, CDCscientists designed experiments to clarify andconfirm the loss of D, L-octanoylcarnitine andfound that using a racemic (equimolar) mixtureof D, L-octanoylcarnitine to calibrate assaysresults in overestimating the concentration ofoctanoylcarnitine in routine blood-spotspecimens because of differences in stability. Thisserious problem could cause measurementerrors, such as false-positive test results. Thus,CDC recommended that laboratories performingthis assay use only L-octanoylcarnitine toproduce assay calibrators. The results of thisstudy demonstrate the importance of assaystandardization and the validation required forclinical screening.

Chace DH, DiPerna JC, Adam BW, Hannon WH.Errors caused by the use of D, L-octanoylcarnitine forblood-spot calibrators. Clin Chem2001;47(4):758–60.

Developing a Fluorescence Intensity StandardSignals a Bright Spot for the Future Assaysbased on the measurement of fluorescenceintensity (FI) have become the most commonmethod of measurement in the biomedicallaboratory. Assays based on FI have highersensitivity than other methods, and themeasurements can be made easily and rapidly.However, no reference materials to ensure theaccuracy of FI measurements have been

available. Accurate FI readings are especiallyimportant for genetic testing and populationscreening. Ongoing research at CDC, the NationalInstitute of Standards and Technology, and theU.S. Food and Drug Administration hasestablished the criteria for accurate FI standardsbased on the equivalent number of solublefluorochrome molecules (MESF). This researchshows that flow and scanning cytometers canaccurately measure as little as 100 MESF onstained particles with a linear dynamic range ofup to 4 decades. These FI standards will allowaccurate measurements on normal andmalignant cells as well as on genes and geneproducts, leading to better data for makingpublic health decisions.

Gaigalas K, Li L, Henderson O, Vogt R, Barr J, MartiG, et al. Development of fluorescence intensitystandards. J Res Natl Inst Stand Technol 2001;106(2):381–9.

Environmental Health Studies

Noise-Induced Hearing Loss May AffectMore Children Than Previously ThoughtExposure to environmental noise can

damage the inner ear’s cilia (tiny hair-like structures)and cause a hearing loss that may be temporary orpermanent. Historically, noise has not beenconsidered a common cause of childhood hearingproblems. More recently, however, researchers havediscovered that noise-induced threshold shiftsactually can contribute to childhood hearingproblems, especially when children are continuallyexposed to excessive noise. Such exposure can lead

On the basis of reviews of audiograms , CDCresearchers estimate that 5.2 million U.S. childrenbetween the ages of 6 and 19 have noise-inducedhearing loss, which can be caused by everydayactivities such as listening to loud music throughheadphones.


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to high-frequency sound discrimination difficulties.The hearing loss may be subtle but can contributeto problems with classroom learning. This kind ofhearing loss is characterized by specific thresholdshifts that can be observed during an audiogram. Todetermine the extent of this problem among U.S.children, CDC analyzed audiograms that had beenperformed as part of the National Health andNutrition Examination Survey (NHANES) III,conducted from 1988 through 1994. A total of5,249 children aged 6 to 19 years completedboth audiometry and compliance testing forboth ears as part of NHANES III. The criteria usedto assess noise-induced threshold shifts includedobservation of a distinct audiometric patterncalled a noise notch in at least one ear. Surveyresults indicated that of those children aged 6to19 years, 12.5% (approximately 5.2 million) areestimated to have noise-induced hearing loss inone or both ears. These findings suggest thatchildren are being exposed to excessive amountsof hazardous levels of noise, and children’shearing is susceptible to damage from theseexposures. Results indicate the need for researchon appropriate hearing conservation methodsand for audiometric screening programs amongschool-aged children.

Niskar AS, Kieszak SM, Holmes A, Esteban E, RubinC, Brody DJ. Estimated prevalence of noise-induced hearing threshold shifts among children6-19 years of age: the third National Health andNutrition Examination Survey, 1988–94—UnitedStates. Pediatrics 2001;108:40–3.

Disinfection By-Products in Tap Water AreCause for Concern Recent epidemiologic studiesof disinfection by-products (DBPs) havesuggested an association between DBPs(generally trihalomethanes [THMs]) in tap waterand adverse reproductive outcomes, includingspontaneous abortion, birth defects, andintrauterine growth retardation. Although moststudies of human reproductive outcome andexposure to THMs have focused on total THMs,recent epidemiologic studies that evaluatedexposure to individual THM species found anincreased risk of spontaneous abortionassociated with exposure to increased levels ofbromodichloromethane levels in drinking water.Both chlorinated and brominated THM species(including chloroform, bromodichloromethane,and bromoform) cause reproductive anddevelopmental toxicity in laboratory animals;however, studies are not clear on which THMspecies pose the greatest potential health risk.CDC staff conducted a field study in 1999 inCorpus Christi, Texas, and Cobb County, Georgia,to evaluate exposure measures for DBPs, with aspecial emphasis on THMs. Participants weremothers living in either geographic area whogave birth to healthy infants from June 1998through May 1999. The study assessed exposureby sampling blood and water and by obtaininginformation about water use habits and tapwater characteristics. Because inhalation ofaerosolized THMs while showering is consideredto be one of the most important and significantroutes of exposure, CDC staff collected two10-mL whole blood samples from eachparticipant before and immediately after hershower. Levels of individual THM species

Mothers who had recently given birth were studiedby CDC in Georgia and Texas to determine levels ofwater disinfection by-products in their blood beforeand after they took a shower.

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(chloroform, bromodichloromethane,dibromochloromethane, and bromoform) weremeasured in whole blood (parts per trillion[pptr]) and in water samples (parts per billion[ppb]). In the Corpus Christi water samples,brominated compounds accounted for 71% ofthe total THM concentration by weight; in CobbCounty, chloroform accounted for 88%. Usingsophisticated analytic techniques, CDC staffwere able to quantify blood levels of individualTHM compounds at extremely low concentrations(pptr), enabling them to discern elevated bloodTHM levels among study participants. Significantdifferences in blood THM levels were observedbetween study locations. For example, themedian baseline blood level of bromoform was0.3 pptr for Cobb County participants and 3.5pptr for Corpus Christi participants (p = 0.0001).Differences were most striking in blood obtainedfrom the mothers after they showered. Forbromoform, the median blood levels were 0.5pptr for Cobb County participants and 17 pptr forCorpus Christi participants (p = 0.0001). Theseresults demonstrate that blood levels of THMspecies vary substantially across populations,depending on both water quality characteristicsand water use activities. Such variation hasimportant implications for epidemiologic studiesof the potential health effects of DBPs. This is thefirst study that (1) documents elevatedbackground levels of individual THMs in humantissue, (2) demonstrates substantial differences inspeciation and blood levels of THMs betweenpopulations served by different water supplysystems, and (3) indicates that THM speciationand levels in blood mirror the THM speciationand levels found in an individual’s water supply.

Lynberg M, Nuckols JR, Langlois P, Ashley D,Singer P, Mendola P, et al. Assessing exposureto disinfection by-products in women ofreproductive age living in Corpus Christi, Texas,and Cobb County, Georgia: descriptive results and methods, 2001. Environ Health Perspect2001;109(6):597–604.

Genetically Engineered Corn Scrutinized OnOctober 25, 2000, the U.S. Food and DrugAdministration requested technical assistancefrom CDC in investigating reports of humanillnesses potentially associated with consumptionof genetically modified corn products. Prior tothese reports, a protein named Cry9c had beeninserted into genetically modified StarLink™ cornand subsequently and inadvertently introducedinto the human food supply. CDC conducted aninvestigation and concluded that (1) the adversehealth events were consistent with allergicreactions to consumption of StarLink™ cornproducts, (2) a temporal association existedbetween product consumption and symptomonset, and (3) neither causation nor exposurecould be verified. Sufficient evidence suggestedthe need for further laboratory assessment of therelation between the allergic reactions and theCry9c protein present in StarLink™ corn. Thefindings did not provide any evidence that theallergic reactions were associated withhypersensitivity to the Cry9c protein. CDCstrongly recommended that participants workwith their health care providers to furtherinvestigate their allergy symptoms. The report isavailable online at http://www.cdc.gov/nceh/ehhe/Cry9cReport.

The U.S. Food and Drug Administration asked CDCto assist in an investigation of whether people hadbecome sick from eating genetically modified cornthat had inadvertently gotten into the food supply.


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Investigation of human health effects associatedwith potential exposure to genetically modifiedcorn. Final report. Atlanta (GA): Dept. of Healthand Human Services (US), Centers for DiseaseControl and Prevention; 2001.

Research Continues on the Possible HealthEffect of Pfiesteria piscicida Since 1996, thepublic health effect of the presence of thedinoflagellate Pfiesteria piscicida in East Coastestuaries has been the subject of considerableresearch activity and controversy. CDC issupporting a number of efforts to determinewhat effect, if any, P. piscicida has on humanhealth. First, CDC has supported the developmentof surveillance for possible estuary-associated

syndrome (PEAS) in six East Coast states(Delaware, Florida, Maryland, North Carolina,South Carolina, and Virginia). From June 1998through June 2001, the PEAS surveillance systemreceived 3,859 calls to request information aboutP. piscicida and similar organisms or to report health effects. Almost all (97.6%) of the calls wererequests for information; however, 91 callsconcerned symptomatic people. Five of these people have been identified as meeting PEAShealth-related criteria; however, theenvironmental data did not conclusively demonstrate exposure to water containingP. piscicida or toxins. Second, CDC is supportingoccupational cohort studies in three states (Maryland, North Carolina, and Virginia) toexamine the potential acute and chronic healthaffects that might result from exposure toP. piscicida or any toxins it may produce. Thesestudies are still in the final data collection stage.Third, in October 2000, CDC sponsored a nationalconference on P. piscicida entitled “From Biologyto Public Health.” CDC convened a panel ofexperts to review the existing scientific literatureand provide CDC with feedback about the futuredirection of P. piscicida research. The panelconcluded that, although a considerable amountof research had been done on P. piscicida, anumber of research gaps need to be addressed.The panel’s summary of future research areasincluded the following topics: the ecophysiologyof P. piscicida, the effects of P. piscicida on fishand other aquatic organisms, methods to detectP. piscicida’s toxins, and epidemiologic and clinical studies.

Pfiesteria piscicida, a microorganism that lives in estuaries in some areas along the East Coast, is being studiedby CDC to determine what effects it may have on human health.

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McGeehin MA, Rubin CH. Pfiesteria: from biologyto public health. Environ Health Perspect2001;109 Suppl 5:633–808.

Potential Impacts of Climate Change andVariability on Human Health Call forPreventive Measures and Additional ResearchCDC reviewed the literature regarding thepotential impacts of climate change andvariability on human health. Findings includedthe following: (1) heat and heat waves arepredicted to increase in severity and frequencywith increasing global mean temperatures; (2)overall death rates are higher in winter than insummer, although the relation between winterweather and mortality is difficult to interpret; and(3) physiologic and behavioral adaptations,

warning systems, and illness management plans may reduce morbidity and mortality from heat orcold. Additional research is needed to do thefollowing: (1) identify critical weather parameters,(2) determine whether any association existsbetween heat and nonfatal illness, (3) evaluatethe implementation of heat response plans, and(4) determine the effectiveness of urban designin reducing heat retention.

McGeehin MA. The potential impacts of climatevariability and change on temperature-relatedmorbidity and mortality in the United States.Environ Health Perspect 2001;109 Suppl 2:185–9.


Global climate change–– which could cause natural disasters such as floods, droughts, and heat waves–– was the topic of a literature review that CDC conducted to determine the potential effects on human health.


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Journal Articles

Adgate JL, Barr DB, Clayton CA, Eberly LE, Freeman NCG, LioyPJ, Needham LL, Pellizzari ED, Quackenboss JJ, Roy A,

Sexton K. Measurement of children's exposure topesticides: analysis of urinary metabolite levels

in a probability-based sample. EnvironHealth Perspect 2001;109(6):583-90.

Backer LC, Esteban E, Rubin CH, KieszakS, McGeehin MA. Assessing acutediarrhea from sulfate in drinkingwater. Journal of the AmericanWater Works Association2001;93(9):76-84.

Backer LC, Grindem CB, Corbett WT,Cullins L, Hunter JL. Pet dogs assentinels for environmental

contamination. Sci Total Environ2001;274:161-9.

Backer LC, Niskar AS, Rubin C, BlindauerK, Christianson D, Naeher L, Rogers HS.

Environmental public health surveillance:possible estuary-associated syndrome.

Environ Health Perspect 2001;109(Suppl 5):797-801.

Balluz L, Moll D, Diaz Martinez MG, Merida Colindres JE, Malilay J.Environmental pesticide exposure in Honduras following Hurricane Mitch.Bull World Health Organ 2001;79(4):288-95.

Balluz L, Philen R, Ortega L, Rosales C, Brock J, Barr D, Kieszak S.Investigation of systemic lupus erythematosus in Nogales, Arizona. Am JEpidemiol 2001;154(11):1029-36.

2001 Publications

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Beskow LM, Khoury MJ, Baker TG, Thrasher JF. Theintegration of genomics into public healthresearch, policy and practice in the United States.Community Genetics 2001;4:2-11.

Binns HJ, Kim D, Campbell C, for the AdvisoryCommittee on Childhood Lead PoisoningPrevention. Targeted screening for elevatedblood lead levels: populations at high risk.Pediatrics 2001;108:1364-6.

Boss LP, Kreutzer RA, Luttinger D, Leighton J,Wilcox K, Redd SC. The public health surveillanceof asthma. J Asthma 2001;38(1):83-9.

Botto LD, Khoury MJ. Commentary: facing thechallenge of gene-environment interaction: thetwo-by-four table and beyond. Am J Epidemiol2001;153(10):1016-20.

Brock JW, Yoshimura Y, Barr JR, Maggio VL, GraiserSR, Nakazawa H, Needham LL. Measurement ofbisphenol A levels in human urine. J Expo AnalEnviron Epidemiol 2001;11(4):323-8.

Brown AS, Gwinn M, Cogswell ME, Khoury MJ.Hemochromatosis-associated morbidity in theUnited States: an analysis of the National HospitalDischarge Survey, 1979–1997. Genetics inMedicine 2001;3(2):109-11.

Buzard N, Spiegel P. Improving standards ininternational humanitarian response: the SphereProject and beyond. JAMA 2001;286(5):531-2.

Cordovado SK, Simone AE, Mueller PW. High-resolution sequence-based typing strategy forHLA-DQA1 using SSP-PCR and subsequentgenotyping analysis with novel spreadsheetprogram. Tissue Antigens 2001;58:308-14.

Cummins SK, Jackson RJ. The built environmentand children's health. Pediatr Clin North Am2001;48(5):1241-52.

Daley WR, Karpati A, Sheik M. Needs assessmentof the displaced population following the August1999 earthquake in Turkey. Disasters2001;25(1):67-75.

Daley WR, Shireley L, Gilmore R. A flood-relatedoutbreak of carbon monoxide poisoning—GrandForks, North Dakota. J Emerg Med 2001;21(3):249-53.

Gao W, Li Z, Kaufmann RB, Jones RJ, Wang Z, ChenY, Zhao X, Wang N. Blood lead levels amongchildren aged 1 to 5 years in Wuxi City, China.Environ Res 2001;87:11-9.

Gorman SE, Dotson DA, Downs KE. Bioterrorism:an overview. Texas Pharmacy 2001;121(3):6-7, 30.

Gorman SE, Downs KE, Dotson DA. Gettinginvolved in terrorism planning: what canpharmacists do? Texas Pharmacy 2001;121(3):22-4

Grandjean P, Weihe P, Burse VW, Needham LL,Storr-Hansen E, Heinzow B, Debes F, Murata K,Simonsen H, Ellefsen P, Budtz-Jørgensen E,


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Keiding N, White RF. Neurobehavioral deficitsassociated with PCB in 7-year-old childrenprenatally exposed to seafood neurotoxicants.Neurotoxicol Teratol 2001;23:305-17.

Grosse S, Gwinn M. Assisting states in assessingnewborn screening options. Public Health Rep2001;116:169-72.

Honein MA, Correa A, Yoon PW, Gambrell D. Isrecall of pregnancy exposures influenced byinterview timing? Am J Epidemiol2001;153(11):S153.

Jason J, Archibald LK, Nwanyanwu OC, Bell M,Jensen RJ, Gunter E, Buchanan I, Larned J,Kazembe PN, Dobbie H, Jarvis WR. The effectsof iron deficiency on lymphocyte cytokineproduction and activation: preservation ofhepatic iron but not at all cost. Clin Exp Immunol2001;126:466-73.

Kaiser R, Henderson AK, Daley WR, Naughton M,Khan MH, Rahman M, Kieszak S, Rubin CH. Bloodlead levels of primary school children in Dhaka,Bangladesh. Environ Health Perspect2001;109(6):563-6.

Kaiser R, Rubin CH, Henderson AK, Wolfe MI,Kieszak S, Parrott CL, Adcock M. Heat-relateddeath and mental illness during the 1999Cincinnati heat wave. Am J Forensic Med Pathol2001;22(3):303-7.

Kelada SN, Shelton E, Kaufmann RB, Khoury MJ.Aminolevulinic acid dehydratase genotype andlead toxicity: a HuGE review. Am J Epidemiol2001;154(1):1-13.

Khoury MJ, Little J. Guidelines for submittinghuman genome epidemiology (HuGE) reviews toTeratology. Teratology 2001;63(2):62-4.

Little RR, Rohlfing CL, Wiedmeyer H-M, Myers GL,Sacks DB, Golstein DE, for the NGSP SteeringCommittee. The National GlycohemoglobinStandardization Program: a five-year progressreport. Clin Chem 2001;47(11):1985-92.

Longnecker MP, Klebanoff MA, Brock JW, Zhou H.Polychlorinated biphenyl serum levels inpregnant subjects with diabetes. Diabetes Care2001;24(6):1099-1101.

Lynberg M, Nuckols JR, Langlois P, Ashley D,Singer P, Mendola P, Wilkes C, Krapfl H, Miles E,Speight V, Lin B, Small L, Miles A, Bonin M, Zeitz P,Tadkod A, Henry J, Forrester MB. Assessingexposure to disinfection by-products in womenof reproductive age living in Corpus Christi, Texas,and Cobb County, Georgia: descriptive results andmethods. Environ Health Perspect2001;109(6):597-604.

Mannino DM. Chronic obstructive pulmonarydisease: epidemiology and evaluation. HospitalPhysician 2001;October:22-31.

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Mannino DM, Caraballo R, Benowitz N, Repace J.Predictors of cotinine levels in US children. Chest2001;120(3):718-24.

Moorman JE, Mannino DM. Increasing U.S.asthma mortality rates: who is really dying? JAsthma 2001;38(1):65-71.

Niskar AS, Kieszak SM, Holmes AE, Esteban E,Rubin C, Brody DJ. Estimated prevalence ofnoise-induced hearing threshold shifts amongchildren 6 to 19 years of age: the Third NationalHealth and Nutrition Examination Survey, 1988-1994, United States. Pediatrics 2001;108(1):40-3.

Ogden CL, Gibbs-Scharf LI, Kohn MA, Malilay J.Emergency health surveillance after severeflooding in Louisiana, 1995. Prehospital andDisaster Medicine 2001;16(3):97-103.

Pawlosky RJ, Flanagan VP, Pfeiffer CM.Determination of 5-methyltetrahydrofolic acid inhuman serum by stable-isotope dilution high-performance liquid chromatography–massspectrometry. Anal Biochem 2001;298:299-305.

Peters U, McGlynn KA, Chatterjee N, Gunter E,Garcia-Closas M, Rothman N, Sinha R. Vitamin D,calcium, and vitamin D receptor polymorphism incolorectal adenomas. Cancer EpidemiolBiomarkers Prev 2001;10:1267-74.

Pfeiffer CM, Gunter EW, Caudill SP. Comparison ofserum and whole blood folate measurements in12 laboratories: an international study. Clin Chem2001;47(6 Suppl):A62-3.

Posada de la Paz M, Philen RM, Abaitua Borda I.Toxic oil syndrome: the perspective after 20 years.Epidemiol Rev 2001;23(2):231-47.

Quandt SA, Arcury TA, Preisser JS, Bernert JT,Norton D. Environmental and behavioralpredictors of salivary cotinine in Latino tobaccoworkers. J Occup Environ Med 2001;43(10):844-52.

Reissman DB, Staley F, Curtis GB, Kaufmann RB.Use of geographic information systemtechnology to aid health department decisionmaking about childhood lead poisoningprevention activities. Environ Health Perspect2001;109(1):89-94.

Rubin CH, Lanier A, Socha M, Brock JW, Kieszak S,Zahm S. Exposure to persistent organochlorinesamong Alaska native women. Int J CirumpolarHealth 2001;60:157-69.

Rubin C, McGeehin MA, Holmes AK, Backer L,Burreson G, Early MC, Griffith D, Levine R, LitakerW, Mei J, Naeher L, Needham L, Noga E, Poli M,Schurz Rogers H. Emerging areas of researchreported during the CDC National Conference onPfiesteria: from biology to public health. EnvironHealth Perspect 2001;109(Suppl 5):633-7.

Ruiz-Méndez MV, Posada de la Paz M, Abian J,Calaf RE, Blount B, Castro-Molero N, Philen R, GelpíE. Storage time and deodorization temperatureinfluence the formation of aniline-derivedcompounds in denatured rapeseed oils. FoodChem Toxicol 2001;39:91-6.


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Salama P, Assefa F, Talley L, Spiegel P, van Der VeenA, Gotway CA. Malnutrition, measles, mortality,and the humanitarian response during a faminein Ethiopia. JAMA 2001;286(5):563-71.

Salama P, Spiegel P, Brennan R. No lessvulnerable: the internally displaced inhumanitarian emergencies. Lancet2001;357:1430-1.

Satten GA, Flanders WD, Yang Q. Accounting forunmeasured population substructure in case-control studies of genetic association using anovel latent-class model. Am J Hum Genet2001;68:466-77.

Schurz Rogers H, Backer L. Fish bioassay andtoxin induction experiments for research onPfiesteria piscicida and other toxicdinoflagellates: workshop summary. EnvironHealth Perspect 2001;109(Suppl 5):769-74.

Smith TL, Smith JM. Electrosurgery inotolaryngology—head and neck surgery:principles, advances, and complications.Laryngoscope 2001;111:769-80.

Spiegel PB, Salama P. Emergencies in developedcountries: are aid organisations ready to adapt?Lancet 2001;357:714.

Spiegel PB, Sheik M, Woodruff BA, Burnham G.The accuracy of mortality reporting in displacedpersons camps during the post-emergencyphase. Disasters 2001;25(2):172-80.

Spierto FW, Gardner F, Smith SJ. Evaluation of anEIA method for measuring serum levels of theestrogen metabolite 2-hydroxyestrone in adults.Steroids 2001;66:59-62.

Steinberg KK, Cogswell ME, Chang JC, Caudill SP,McQuillan GM, Bowman BA, Grummer-Strawn LM,Sampson EJ, Khoury MJ, Gallagher ML.Prevalence of C282Y and H63D mutations in thehemochromatosis (HFE) gene in the UnitedStates. JAMA 2001;285(17):2216-22.

Taylor L, Jones RL, Kwan L, Deddens JA, Ashley K,Sanderson WT. Evaluation of a portable bloodlead analyzer with occupationally exposedpopulations. Am J Ind Med 2001;40:354-62.

Thomas AR, Marcus M, Zhang RH, Michels BlanckH, Tolbert PE, Hertzberg V, Henderson AK, Rubin C.Breast-feeding among women exposed topolybrominated biphenyls in Michigan. EnvironHealth Perspect 2001;109(11):1133-7.

Vesper HW, Smith SJ, Audain C, Myers GL.Comparison study of urinary pyridinoline anddeoxypyridinoline measurements in 13 USlaboratories. Clin Chem 2001;47(11):2029-31.

Wang SS, FitzSimmons SC, O'Leary LA, Rock MJ,Gwinn ML, Khoury MJ. Early diagnosis of cysticfibrosis in the newborn period and risk ofPseudomonas aeruginosa acquisition in the first10 years of life: a registry-based longitudinalstudy. Pediatrics 2001;107(2):274-9.

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Wang SS, Fridinger F, Sheedy KM, Khoury MJ.Public attitudes regarding the donation andstorage of blood specimens for genetic research.Community Genetics 2001;4:18-26.

Yang QH, Khoury MJ, Friedman JM, Flanders WD.On the use of population attributable fraction toestimate sample size required in case-controlstudy of gene-environment interaction. Am JEpidemiol 2001;153(11):S86.

Zhang M, Gunter EW, Pfeiffer CM. Evaluation ofthe Drew Scientific DS30 homocysteine assay incomparison with the Centers for Disease Controland Prevention reference HPLC method. ClinChem 2001;47(5):966-7.

Book Chapters

Hollowell JG, Therrell BL, Hannon WH. Congenitalhypothyroidism. In: Wald N, Leck I, editors.Antenatal and neonatal screening. 2nd ed. NewYork: Oxford University Press; 2000. p. 370-97.

Jackson RJ, Rubin CH, McGeehin M. Sensitivepopulation groups. In: Krieger RL, editor.Handbook of pesticide toxicology. 2nd ed. Vol 1.San Diego (CA): Academic Press; 2001. p. 783-94.

Lopes Cardoza B, Salama P. Mental health ofhumanitarian aid workers in complexemergencies. In: Danieli Y, editor. Sharing thefront line and the back hills: peacekeepers,humanitarian aid workers and the media in the

midst of crisis. Amityville (NY): BaywoodPublishing; 2001. p. 242-55.

Book Review

Rubin C. Review of environmental endocrinedisrupters: an evolutionary perspective, edited byLJ Guillette Jr and DA Crain [book review].Paediatr Perinat Epidemiol 2001;15:201-3.

Brochure

Centers for Disease Control and Prevention(CDC). National report on human exposure toenvironmental chemicals [brochure]. Atlanta:CDC, 2001.

Letters to the Editor

Grosse S. Screening for medium chain acyl-CoAdehydrogenase deficiency has still not beenevaluated [letter]. BMJ 2001;322(7278):112.

Grosse SD, Khoury MJ, Hannon WH, Boyle CA.Early diagnosis of cystic fibrosis [letter]. Pediatrics2001;107(1):1492.

Grosse SD, Morris JM, Khoury MJ. Disease-relatedconditions in relatives of patients withhemochromatosis [letter]. N Engl J Med2001;344(19):1477-8.


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Manuals

Centers for Disease Control and Prevention (CDC).The public health response to biological andchemical terrorism: interim planning guidance forstate public health officials. Available fromURL: http://www.bt.cdc.gov/document/planning/planning; 2001.

Vessel Sanitation Program. Recommendedshipbuilding construction guidelines for cruisevessels destined to call on U.S. ports. Atlanta:Centers for Disease Control and Prevention; 2001.

Proceedings

Batts-Osborne D, Balluz L, Naughton M.Assessment of public health needs amongdisplaced persons residing in a temporarycamp following the August 1999 earthquakesin Turkey. In: Cauffman SA, editor. Wind andseismic effects. Proceedings of the 32nd JointMeeting of the U.S.-Japan Cooperative Programin Natural Resources Panel on Wind and SeismicEffects; 2001 May 16-19; Gaithersburg (MD).Gaithersburg (MD): National Institute ofStandards and Technology; Special Publication963; 2001. p. 401-4.

Daley WR. Post-disaster carbon monoxidepoisoning: an emerging health problem. In:Cauffman SA, editor. Wind and seismic effects. Proceedings of the 32nd Joint Meeting of the

U.S.-Japan Cooperative Program in NaturalResources Panel on Wind and Seismic Effects;2001 May 16-19; Gaithersburg (MD). Gaithersburg(MD): National Institute of Standards andTechnology; Special Publication 963; 2001. p. 1-4.

Frick EA, Henderson AK, Moll DM, Furlong ET,Meyer MT. Presence of pharmaceuticals inwastewater effluent and drinking water,Metropolitan Atlanta, Georgia, July–September1999. In: Hatcher KJ, editor. Proceedings of the2001 Georgia Water Resources Conference; 2001Mar 26-27; Athens (GA). Athens: University ofGeorgia, Institute of Ecology; 2001. p. 282.

Grosse SD. Cost-benefit and cost effectiveness ofnewborn screening programs: concepts andexamples. In: Proceedings: 14th NationalNeonatal Screening Symposium: Gateway to the21st Century; 1999 September 8-10; St. Louis(MO). Washington (DC): Association of PublicHealth Laboratories; 2001. p. 38-42.

Miller CW, Bouville A, Anspaugh L, Beck H, GilbertE, Qualters JR, Simon S, Whitcomb Jr RC. Resultsof a feasibility study of the health consequencesto the American population of nuclear weaponstests conducted by the United States and othernations. In: Exposure analysis: an integral part ofdisease prevention. Abstracts. 11th AnnualMeeting, International Society of ExposureAnalysis; 2001 Nov 4-8; Charleston (SC).Charleston: Society of Exposure Analysis; 2001. p.47-8.

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Zhang M, Gunter EW, Pfeiffer CM. Comparison ofthe Drew Scientific DS30 homocysteine assaywith the CDC reference HPLC method. In:Experimental Biology 2001 Abstract Book Part 1;2001 Mar 31-Apr 4; Orlando (FL). Bethesda (MD):Experimental Biology; 2001. p. A613.

Report

Sage MJ, Jones GA, Qualters J, Needham L, YeskeyK, De Rosa C, Reyes J, Gist G, Christenson G.Shared vision: report of the CDC/ATSDR WorkingGroup on a Shared Vision for EnvironmentalPublic Health at CDC/ATSDR. Atlanta: Centers forDisease Control and Prevention and Agency forToxic Substances and Disease Registry; 2001.

Morbidity and Mortality Weekly Reports

Nosocomial poisoning associated withemergency department treatment oforganophosphate toxicity—Georgia, 2000.MMWR 2001;49(51):1156-8.

Hypothermia-related deaths—Suffolk County,New York, January 1999–March 2000, and UnitedStates, 1979–1998. MMWR 2001;50(4):53-7.

Blood and hair mercury levels in young childrenand women of childbearing age—United States,1999. MMWR 2001;50(8):140-3.

Notice to Readers: Satellite broadcast on a publichealth response to asthma. MMWR2001;50(13):248-9.

Using tandem mass spectrometry for metabolicdisease screening among newborns: a report of awork group. MMWR 2001;50(RR-3):1-34.

Mortality during a famine—Gode District,Ethopia, July 2000. MMWR 2001;50(15):285-8.

Trends in blood lead levels among children—Boston, Massachusetts, 1994–1999. MMWR2001;50(17):337-9.

Are women with recent live births aware of thebenefits of folic acid? MMWR 2001;50 (RR-6):1-14.

Protracted outbreaks of cryptosporidiosisassociated with swimming pool use—Ohio andNebraska, 2000. MMWR 2001;50(20):406-10.

Prevalence of parasites in fecal material fromchlorinated swimming pools—United States,1999. MMWR 2001;50(20):410-2.

Notice to Readers: Responding to fecal accidentsin disinfected swimming venues. MMWR2001;50(20):416-7.

Fatal pediatric lead poisoning—New Hampshire,2000. MMWR 2001;50(22):457-9.


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Racial disparities in median age at death ofpersons with Down syndrome—United States,1968–1997. MMWR 2001;50(22):463-5.

Vitamin A deficiency among children—Federated States of Micronesia, 2000. MMWR2001;50(24):509-12.

Heat-related deaths—Los Angeles County,California, 1999–2000, and United States,1979–1998. MMWR 2001;50(29):623-6.

Updated guidelines for evaluating public healthsurveillance systems: recommendations from theGuidelines Working Group. MMWR 2001;50(RR-13):1-36.

Self-reported asthma prevalence among adults—United States, 2000. MMWR 2001;50(32):682-6.

Notice to readers: National Lead PoisoningPrevention Week—October 21–27, 2001. MMWR2001;50(42):927-8.

Surveillance of mortality during a refugee crisis—Guinea, January–May 2001. MMWR2001;50(46):1029-32.

EPI-AID Investigations

Albalak R, Hart R, Noonan G, Kim D, et al. Bloodlead levels and risk factors for lead poisoningamong children, Torreon, Coahuila, Mexico.March 5, 2001; EPI-2001-34.

Joskow R, Kaiser R, Belson M, Vesper H. Sudden,unexplained death, Haiti. March 15, 2001; EPI-2001-38.

Daley WR. Assessment of water, sanitation, andhealth status in earthquake-damaged areas ofGujarat, Gujarat State, India. May 4, 2001; EPI-2001-48.

Kim D, Albalak R, Buchanan S, Noonan G. Bloodlead levels and risk factors for lead poisoning andanemia among children, Jakarta, Indonesia. May29, 2001; EPI-2001-51.

Brown L, Kim D, Buchanan S, Noonan G. Leadpoisoning associated with tamarind candies. July12, 2001; EPI 2001-58.

Winterton B, Batts-Osborne D, Daley WR.Assessment of the impact of Tropical StormAllison flooding on hospital infrastructure andemergency department visits. July 24, 2001; EPI2001-59.

Sarisky J, Mainzer H, Stock A, Brown C. Suspectedillness associated with living in flood-damagedhomes. August 27, 2001; EPI 2001-64.

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