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Table of Contents
Opening Session
Update by the BSC Executive Secretary
Update by the ATSDR Assistant Administrator
ATSDR's Emergency Response Servcies (ERS)
ATSDR's Activities at the Toms River, New Jersey Site
ATSDR/NCEH SharedVision for Environmental Public Health
Public Comment Period
BSC Open Discussion
CTS Report
ATSDR's Recent Site Activities
•Viegues, Purerto Rico
•Fallon, Nevada
•Libby Montana
Public Comment Period
BSC Business
•Action Items/Recommendations
•Agenda Items
Closing Session 

The U.S. Public Health Service (PHS), the Department of Health and Human Services (HHS), and the Agency for Toxic Substances and Disease Registry (ATSDR or the Agency) convened a meeting of the Board of Scientific Counselors (BSC). The proceedings were held at the Sheraton Colony Square Hotel in Atlanta, Georgia on November 15-16, 2001. The following individuals were present to contribute to the discussion.

BSC Members
Dr. Charles Sorber, Acting Chair
Dr. William Au
Dr. Rosemarie Bowler
Dr. James Collins
Dr. Millicent Collins
Dr. Cynthia Harris
Dr. Melissa McDiarmid
Dr. Jeffrey Roseman
Dr. LuAnn White

BSC Ex Officio Members
Dr. David Bennett (EPA)
Dr. Buck Grissom (NIEHS)

CTS Special Consultants
Ms. Cynthia Babich
Ms. Doris Bradshaw
Ms. Linda Gillick [via conference call]
Ms. Vivian Jones
Ms. Anna Rondon-Manuelito
Ms. LeVonne Stone

Designated Federal Official
Dr. Robert Spengler, Executive Secretary

ATSDR Representatives
Dr. Henry Falk, Assistant Administrator
Dr. Michael Allred
Dr. Robert Amler
Ms. Janna Brooks
Dr. Gary Campbell
Ms. Sharon Campolucci
Dr. Christopher DeRosa
Ms. Diane Drew
Ms. Rita Ford
Mr. Richard Gillig
Ms. Carolyn Harper
Ms. Marianne Harkin
Dr. Heraline Hicks
Dr. James Holler
Dr. Elizabeth Howze
Dr. Robert Johnson
Ms. Georgi Jones
Dr. Wendy Kaye
Dr. Edwin Kilbourne
Ms. Penny Lampe
Mr. Michael Lewin
Ms. Shirley Little
Ms. Sandra Lopez
Dr. Jeffrey Lybarger.
Ms. Sandra Malcom
Mr. Morris Maslia
Mr. Peter McCumiskey
Dr. Moiz Mumtaz
Ms. Dawn O'Connor
Dr. Ralph O'Connor
Ms. Donna Orti
Dr. Stephanie Ostrowski
Ms. Ruby Palmer
Dr. Lucy Peipins
Mr. Juan Reyes
Mr. Kevin Ryan
Ms. Donna Rossie
Ms. Gail Scogin
Dr. Lester Smith
Dr. Allan Susten
Ms. Maria Teran-MacIver
Dr. Pamela Tucker
Mr. James Tullos, Jr.
Dr. Richard Weston
Dr. Sharon Williams-Fleetwood
Dr. David Williamson
Mr. Michael Youson

Presenters and Guests
Dr. Henry Anderson (NCEH Advisory
Committee) [via conference call]
Dr. Thomas Burke (NCEH Advisory
Committee) [via conference call]
Dr. Jerald Fagliano (New Jersey DOH)
Dr. Richard Jackson (CDC/NCEH)
Mr. Michael Kashden (CDC/OGC)
Ms. Priscilla Patin (CDC/NCEH)
Dr. Carol Rubin (CDC/NCEH)
Mr. Michael Sage (CDC/NCEH)
Ms. Brandy Tomhave (TASWER).

Opening Session. Dr. Charles Sorber, the Acting BSC Chair, called the meeting to order at 8:40 a.m. on November 15, 2001. He welcomed the attendees to the proceedings, opened the floor for introductions, and entertained a motion to approve the minutes of the previous meeting. A motion was placed on the floor and seconded. There being no changes or further discussion, the May 3-4, 2001 BSC meeting minutes were unanimously approved.

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Update by the BSC Executive Secretary. Dr. Robert Spengler's report covered four areas. First, the status of the action items and recommendations raised during the previous BSC meeting are as follows.

· ATSDR will track publications using the annual publications list and distribute the 2001 publications at the next BSC meeting.
· ATSDR is currently making efforts to identify resources for its Agenda for Public Health Environmental Research (APHER). In FY'02, $300,000 was set aside; $1 million is expected to be allocated to APHER in FY'03.
· ATSDR will keep the Community Tribal Subcommittee (CTS) informed about the new state health department subcommittee. The CTS Chair and BSC Executive Secretary will coordinate activities between the two groups.
· ATSDR supports the function changes the BSC proposed for its charter.
· ATSDR will ensure that its strategic plan goals focus on prevention and action.
· ATSDR will support the collection of biomedical specimens from comparison populations in exposure investigations when appropriate.
· ATSDR will make every effort to distribute pre-meeting materials that provide relevant background information and specific questions to ensure the BSC is better prepared for discussions. ATSDR will consider developing a one-page form that briefly describes the presentation, materials, objectives and questions.
· ATSDR will support efforts to increase and strengthen its Physician Education Program as recommended by the BSC.
· The National Center for Environmental Health (NCEH) Advisory Committee (NAC) could not form a quorum and will be unable to hold a joint meeting with the BSC. However, two NAC members will be joining the BSC meeting by conference call during the afternoon session.
· BSC members will be asked to collaborate with the Executive Secretary in developing a mechanism to evaluate the effectiveness or implementation of BSC recommendations.
· ATSDR will review sites where it has provided physician education over the past ten years and compare these findings to Health Resources Services Administration (HRSA) medically underserved areas.

Second, the three APHER projects ATSDR funded in FY'01 focused on ethyl mercury, assessment tools to better evaluate stress levels in children who live near hazardous waste sites, and identification of a large cohort of former workers in a plant with drinking water contaminated by TCE. In FY'02, ATSDR received 23 concept proposals to conduct APHER projects. The total funding request is more than $2.5 million for both extramural and intramural research. ATSDR will form a review committee to evaluate the merit of the proposals and select applications that will be recommended for funding in FY'02.

Third, ATSDR, the National Institute for Environmental Health Sciences (NIEHS) and the U.S. Environmental Protection Agency (EPA) jointly developed a special supplement for the International Journal of Hygiene and Environmental Health. The 21 articles will discuss the Superfund research programs in all three agencies, provide examples, describe collaborative efforts and present future research goals for each agency. The supplement will be distributed to the BSC after publication. Fourth, efforts to establish the new health department subcommittee have been delayed due to hiring freezes in the federal government. However, ATSDR has distributed letters to various organizations requesting the names of potential nominees.

Dr. Henry Falk, the ATSDR Assistant Administrator, presented plaques to acknowledge three BSC members whose terms will expire November 30, 2001: Drs. Millicent Collins, Jeffrey Roseman and LuAnn White. The attendees joined Dr. Falk in recognizing and applauding the valuable contributions these members have made during their tenure on the BSC.

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Update by the ATSDR Assistant Administrator. Dr. Falk's report covered the following areas. First, the new budget process that was initiated in FY'01 provides ATSDR with an independent account in its Congressional subcommittee. The traditional method was for EPA to present ATSDR's budget request to Congress and the Office of Management and Budget (OMB). With the new process, ATSDR is able to make its own case for funding and strengthen relationships with HHS, OMB and Congress. However, ATSDR has strongly emphasized to EPA and Congress that the close partnership between the two agencies in conducting Superfund activities will not be affected by the new budget process. The Senate and House both agreed with the President's FY'02 budget request. This figure represents a $3.5 million increase to ATSDR.

ATSDR is also strengthening its partnership with NIEHS. The two agencies have established a joint planning group to improve collaborative efforts in conducting Superfund research. Second, four sites continue to be priority areas for ATSDR. In Vieques, Puerto Rico, ATSDR conducted several evaluations and investigations of health concerns related to operations conducted by the U.S. Navy. The Agency's activities included public health assessments (PHAs) of soil, air water and food. Additionally, a study was reevaluated that found increased thickening of the pericardium among Vieques fishermen. An independent panel of four peer reviewers from the United States and four from Spanish speaking countries was established for this effort. The new data did not corroborate the findings of the original study.

In Fallon, Nevada, ATSDR and the Centers for Disease Control and Prevention (CDC) engaged in a joint effort with the state health department to investigate a cluster of childhood leukemia cases. ATSDR is evaluating environmental data, while CDC is conducting a case control study. The Toms River, New Jersey site serves as a model of technical enhancements ATSDR designed to consider the role of drinking water contaminants in childhood leukemia cluster investigations. The results of the study will be disseminated in December 2001. In Libby, Montana, ATSDR clinically confirmed several hundred cases of asbestos-related disease. Of nearly 7,000 residents who were examined, 20% showed x-ray abnormalities of pleural plaques. Detailed reports of activities at the four sites will be presented during the BSC meeting.

Third, ATSDR responded to the Pew Commission recommendations during testimony at a Senate committee field hearing, a briefing with the HHS Secretary and testimony at a Senate subcommittee. Fourth, the ATSDR/NCEH Shared Vision for Environmental Public Health will be discussed in detail during the afternoon session with NCEH staff and NAC members. Fifth, ATSDR responded to terrorism by deploying staff to New York City and Washington, DC, addressing anthrax concerns, and providing emergency response (ER) services. ATSDR provided guidance and expertise to agencies at federal, state and local levels in toxic substance releases, remediation and environmental sampling.

Sixth, ATSDR has filled leadership positions at the Director and Deputy Director levels in three divisions. The Associate Administrator of Toxic Substances and Public Health is a new position that has been created and filled in the Office of the Assistant Administrator. Seventh, ATSDR is continuing to refine performance measures and conduct other activities for APHER and the 2002-2007 strategic plan. In response to Dr. Au, Dr. Falk announced that a joint meeting will be held in January 2002 to discuss mechanisms to link the ATSDR Pediatric Environmental Health Speciality Units and the EPA/NIEHS Children's Centers for Excellence. The agencies have asked the American Academy of Pediatrics and the March of Dimes to partner in this effort by training pediatricians in environmental health.

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ATSDR's Emergency Response Section (ERS). Dr. Christopher DeRosa explained that ATSDR's ERS services are available throughout the country 24 hours per day each day of the week. After a call is received on the hotline, ATSDR can contact an emergency operations coordinator within ten minutes and deploy a multi-disciplinary team to the site within eight hours. The standing members of the team include an ERS coordinator, toxicologist, chemist, medical officer, radiological health physicist and other expertise as needed. Callers who access the 24-hour hotline can obtain site- or event-specific answers to questions.

In responding to emergencies, ATSDR conducts the following activities: develops a written or oral assessment of the public health impact of the incident; describes combustion or reaction byproducts; assists in creating a sampling or monitoring plan; provides information on chemical and toxicological properties; reviews and analyzes data; answers questions about worker safety and health; makes recommendations about secondary exposure prevention; and offers guidance on medical management issues. ATSDR's ERS clients include EPA, the U.S. Coast Guard, pre-hospital and hospital providers, the public, as well as health, public safety, environmental and emergency management agencies at federal, state and local levels.

ATSDR uses existing resources to prepare for and respond to emergencies. The documents are posted on the web site and are also distributed to the National Response Team of 16 federal agencies. Toxicological profiles are available on CD-ROM and describe the 250 hazardous substances most commonly associated with commercial, industrial or emergency releases. The profiles also characterize reproductive, developmental, respiratory or other health effects related to chemicals. ToxFaqs are one- or two-page summaries responders can use to quickly obtain answers to frequently asked questions about exposures to hazardous substances.

Public health statements are documents that describe the toxicological profiles in easily understandable language. The summaries focus on toxic substances and human health effects from exposures. Both the ToxFaqs and public health statements have been updated to include pediatric modules. Recommendations to manage hazardous materials incidents can be obtained in hard copy or on the "Community Challenge" videotape. Volumes 1 and 2 are targeted to first responders and health care providers and are used as a planning guide for the management of contaminated patients. Volume 3 outlines medical management guidelines for acute chemical exposures, including a description of health effects for pre-hospital and emergency department management as well as a patient information sheet if follow-up is necessary after treatment.

The CD-ROM versions of the toxicological profiles have been distributed to all U.S. school districts to provide guidance on appropriate measures that should be taken in emergency or accidental events. Communities and other groups at the local level can obtain the CD-ROMS from state or local health authorities. Additionally, over 400,000 copies of the medical management guidelines have been disseminated to individuals and local groups to date. However, ATSDR realizes that more proactive measures must be taken to increase awareness about the availability of its ERS resources. Collaborative efforts are being undertaken with the Federal Emergency Management Agency (FEMA) and other federal and state partners to disseminate ERS materials on a wider basis. Target audiences include fire departments, first responders, hospitals, police departments and community-based organizations.

Partnerships have also been developed at both department and agency levels to provide ERS services. ATSDR serves as the lead HHS agency on the National Response Team. The advisory group holds monthly meetings to assist in developing or revising federal emergency policies and provide guidance to 13 regional response teams. The standing committees address response, preparedness, training, and science and technology. For the HHS Office of Emergency Preparedness, ATSDR participates in monthly calls with emergency coordinators, engages in simulations or practice exercises with top officials, and provides assistance at incident-specific preparedness events, such as the Republican and Democratic conventions, the Olympics and hurricanes.

For the September 11, 2001 terrorism attacks, nearly 700 HHS staff were deployed to New York City and Washington, DC, including disaster medical assistance teams, disaster mortuary operation response teams, epidemiologists, veterinarians and forensic dentists. At the agency level, ATSDR staff were deployed to CDC's 24-hour Emergency Operation Center in Atlanta. Both agencies maintain 24-hour response lines; however, CDC takes the lead in emergencies for natural disasters, oil and petroleum releases and bioterrorism, while ATSDR is responsible for hazardous chemical releases. Agreement has been reached for the response group that receives a call to proceed with activities until transfer to the lead agency is appropriate. In FY'01, $400,000 were allocated to ATSDR under CDC's bioterrorism budget. The funding was used to develop medical management guidelines for ten additional substances and print a color-coded notebook edition for quick reference in emergency situations.

Dr. Robert Johnson described specific incidents in which ATSDR's ERS services were used to respond to disasters. For the September 11, 2001 terrorism attacks, ATSDR deployed field teams to New Jersey and New York and established Atlanta-based support teams with expertise in toxicology, community involvement and Geographic Information Systems (GIS). Specifically for the World Trade Center (WTC), ATSDR served on the Environmental Assessment Workgroup with representatives of federal agencies that are primarily responsible for environmental and occupational health. The workgroup was formed to coordinate federal support to New York's city and state health departments. The three workgroup chairs represented ATSDR, EPA and the Occupational Safety and Health Administration.

The workgroup made several accomplishments. One central federal database was created for all environmental sampling results. Fact sheets and other risk communication activities were coordinated. Technical fact sheets and screening guidelines for asbestos, dioxins, PCBs and particulate matter were quickly distributed to EPA and the New York City Department of Health. Assistance was provided to the health department in developing and conducting a residential sampling plan to ensure appropriate cleanup. ATSDR took ambient and indoor samples to evaluate the public health of residents near the WTC. This information will not be released for several weeks, but the data will be used to assist public health agencies in determining the potential for environmental exposures and health implications related to materials from the WTC collapse. If the residential samples show contaminants at levels of concern, building owners and individual tenants will be notified and public health actions will be taken.

EPA took the lead in managing the sampling data collected by the workgroup, while ATSDR oversaw the residential sampling plan. The workgroup also attended several public meetings the health department organized with community groups, tenant associations, building owners and local residents. Despite these efforts, EPA received negative coverage by the media about its ability to provide real-time responses to the massive amount of information that was gathered. As one of the workgroup members, ATSDR realizes that EPA made a tremendous effort to receive data from a variety of sources and distribute the information on a timely basis. ATSDR also acknowledges the fact that some media outlets in New York provided inaccurate reports to the public in terms of onsite versus offsite results of outdoor samples.

The findings to date are as follow. Asbestos, particulate matter, dioxins, PCBs, metals, volatile organic compounds (VOCs) and other offsite contaminants were found to be at levels too low to pose health risks, but health and safety risks to workers at ground zero are of grave concern. During the first 48 hours after the WTC event, most first responders were not wearing protective equipment. However, asbestos, particulate matter, benzene and other substances were found to be at levels high enough to recommend respiratory protection. Smoke from smoldering fires at the WTC is expected to continue for several more months. ATSDR recognizes that stronger efforts must be made to emphasize to first responders the importance of wearing protective equipment at all times during emergency events.

In response to the anthrax investigations, more than 90 ATSDR staff members currently serve on response teams to operate CDC's 24-hour telephone number, address occupational environmental concerns and provide field services in Florida, New Jersey and the Washington, DC/Capitol Hill area. ATSDR's occupational environmental team operates in two shifts per day seven days per week with ten staff members. Solutions and consultation are provided by telephone, fax and e-mail to the CDC Emergency Response Center, field teams, other government agencies, first responders, business and industrial sectors, as well as private citizens. The team also wrote and reviewed guidance documents and field protocols for use within and outside of CDC. These recommendations address several high-priority areas: anti-microbial prophylaxis to prevent anthrax among cleanup workers; protection to mail handlers; protective clothing and respirators; facility cleanup; suspicious powder samples and other laboratory guidance; procedures to collect environmental samples; and post-cleanup closure sampling.

ATSDR's anthrax field teams provided support to EPA headquarters; EPA regional offices in Capitol Hill, Florida and New Jersey; and health and safety regional representatives. The teams addressed several issues, including sampling, site entry, health and safety plans, decontamination and cleanup. GIS played in important role in ATSDR's ERS services for the WTC disaster and anthrax investigations. Information generated with this technology included sampling location maps, asbestos level trend maps, demographic analyses to locate sampling locations, and footprint maps in buildings to assist sampling teams. GIS is also being used to follow locations of anthrax samples, track laboratory capacity every 48 hours, and create maps of buildings to show cleanup results. On a broader scale, ATSDR expects to apply these findings to improve ERS services at other sites in the future.

Mr. Peter McCumiskey outlined additional activities ATSDR undertakes to respond to chemical, biological and radiation events. For chemical terrorism, ATSDR partners with NCEH to provide a public health response and coordinates activities with CDC, EPA, FEMA, the Chemical Safety Board and state agencies. Consultations in the areas of toxicology, medicine, health and safety, engineering and industrial hygiene are provided as well. ATSDR also supports CDC's emergency operation center through a 24-hour day/ seven-day week response desk, a part-time state liaison epidemiology desk, membership on the occupational and environmental workgroup, and GIS technical support.

For the WTC attack, ATSDR provided expertise in clinical care and forensic dentistry by deploying staff to the Commission Corps Readiness Force under 30-day temporary assignments. ATSDR is also using a bioterrorism coordinator to oversee activities and facilitate data from various agencies that responded to the WTC attack. Over the past four years, ATSDR has submitted funding proposals to the CDC bioterrorism program to build its skills and those of states to respond to chemical terrorist events. The purposes of these requests were to train local health departments in industrial and chemical terrorism; develop additional medical management guidelines for training and response services; expand ATSDR's hazardous substances surveillance system; enhance rapid reporting; and build capacity at state and local levels in providing ERS consultations.

Ms. Georgi Jones reported that the September 11, 2001 attacks caused ATSDR to reevaluate the initiatives and submit five new proposals to CDC to enhance its role in chemical terrorism. These funding requests have been made in an effort to achieve the following goals. First, strengthen capacity and increase chemical terrorism staff in ATSDR and its 33 grantees in states, Puerto Rico and an Indian reservation. Second, closely collaborate with health care providers to enhance training efforts, increase the chemical management guidelines to 100 documents, and effectively and widely disseminate the data by implementing outreach activities to partners in medical associations and hospitals. Third, expand the Hazardous Substances Emergency Event Surveillance System from 16 states to all 50, engage in collaborative efforts with poison control centers, and design online versions of information from these sources for broader access.

Fourth, determine if data from the Pew Environmental Health Tracking Program can be applied to terrorism events. Neurological diseases have been selected as the first focus area of this initiative. Fifth, design more effective mechanisms to use GIS in planning for terrorism events by monitoring facilities that store or produce a massive amount of chemicals onsite. The enhanced GIS capability would also pinpoint heavily populated areas and hospitals to determine locations with the most critical need for ER training and evacuation plans. Dr. Falk and four other high-ranking officials in CDC recently met with Dr. Jeffrey Koplan, the ATSDR Administrator/CDC Director, to emphasize the need for the agencies to improve abilities in responding to and preparing for emergencies related to chemical and radiological terrorism as well as mass trauma explosive events.

Dr. Koplan directed the agencies to formulate strategies to address this concern, but CDC has not yet responded to ATSDR's five proposals. In the initial stages of the planning effort, ATSDR and CDC will define the role of public health agencies in addressing potential scenarios and collaborating with other onsite responders; assess existing capabilities and limitations of public health agencies at federal, state and local levels; identify data needed to fill current gaps; and explore opportunities to develop partnerships.

Discussion. Dr. Roseman suggested that ATSDR partner with the Food and Drug Administration to widely publicize its ERS services. Individuals generally take antibiotics and antidotes for long periods of time after chemical terrorism events, but epidemiologic data and risk assessments from these medications are usually poor. Dr. Falk confirmed that agencies have been monitoring visits to hospitals and private physicians to track side effects among postal workers and other groups who have been taking anthrax antibiotics for a 60-day period. However, he agreed that a solid database should be developed to follow adverse health effects from medications taken after an emergency event.

Dr. M. Collins was concerned that in a chemical terrorism event, patients who do not present to hospital physicians will be missed because ATSDR's ERS services appear to be targeted to doctors in these facilities. At a national convention, she recently learned that physicians' knowledge about anthrax and abilities to access this type of information significantly differ. Dr. Falk mentioned that FEMA and ATSDR will create a joint workgroup to enhance chemical medical preparedness skills in a variety of settings, including hospitals, private doctor offices, clinics and emergency rooms.

Dr. Au inquired about ATSDR's capacity to sustain a high level of involvement in terrorism activities with no new funding and without jeopardizing its Congressional mandate to address environmental health concerns in communities and tribes. Dr. Falk conveyed that he will continue to strongly emphasize to the HHS Secretary and Congress the need to allocate additional resources if ATSDR will be expected to sustain a long-term effort in terrorism activities.

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ATSDR's Activities at the Toms River, New Jersey Site. Mr. Juan Reyes noted that the investigation at the site of 80,000 residents required a five-year effort. The community currently encompasses two sites on the National Priorities List (NPL) and previously included a municipal landfill with industrial wastes. According to EPA at both federal and state levels, the three sites have contributed to contamination of groundwater that serves as a drinking water source in the community. Prior to 1995, ATSDR identified public health threats at the sites, took follow-up actions through consultations, and closely collaborated with the state in developing environmental health capacity and addressing health issues related to hazardous wastes.

In 1995, the community and a nurse contacted ATSDR to express concerns about the large number of childhood cancer cases in the area. Based on an initial review of cancer registry data and information from other existing sources, ATSDR and the state identified an increased incidence of childhood leukemia as well as brain and central nervous system (CNS) cancers in the community. These findings led to a true partnership among the community and agencies at federal, state and local levels. The results also served as the driving force in developing a public health response plan that was agreed to and endorsed by all participating groups. The goals of this initiative were to identify environmental exposures to hazardous substances, evaluate potential risks for childhood cancer, and take preventive actions to reduce future exposures.

The public health response plan provided a framework for initial and future actions in the investigation and clearly delineated responsibilities and roles of all partners and stakeholders. ATSDR engaged in several activities under the plan. First, PHAs were completed in three locations and consultations were provided at two sites to address potential exposure to contaminants from a nearby facility. Second, exposure characterizations were refined by supplementing existing data from EPA and the state with additional environmental sampling. In this effort, the drinking water quality was analyzed to detect chemical or radiological characteristics; private wells and soil from areas of known and suspected waste sites were tested; and ambient air samples were taken from two locations.

To address concerns related to past exposures from contaminated air and groundwater, an environmental analysis was conducted of attic dust from 150 homes and modeling was performed to reconstruct historic dust deposition, air pollution sources and water distribution. The air and water modeling results are being considered as risk factors in the case control study ATSDR is implementing in the community. Third, the epidemiologic evaluation was based on a 1979-1995 cancer incidence analysis, but ATSDR and the state later developed a protocol and questionnaire for a case control study. The research focused on the role of lifestyle or residential, occupational and environmental risk factors in childhood leukemia and brain cancer.

This effort led to the initiation of a case control study of childhood leukemia and brain cancer in multiple states with similar health concerns, such as Florida, New Jersey, New York and Pennsylvania. Over the last 30 years, the incidence of CNS cancers has increased 40% among U.S. children. Fourth, a toxicological analysis was implemented through evaluations and estimations of biological effects by the computational toxicology laboratory; animal studies in styrene-acrylonitrile trimer (SAT) to detect chronic non-cancerous and neurological effects during the perinatal period; and extensive consultations and literature reviews of substances potentially related to leukemia and CNS cancers.

Fifth, public meetings were held on a regular basis as part of the community outreach and educational effort. Local residents and other stakeholders were informed about ongoing initiatives and research results; concerns were addressed in a timely manner; and citizen guides were distributed as an additional source of information. Strong efforts were made to coordinate with other agencies. Indeed, the state established a field office in the county medical center to provide local residents and health professionals with frequent updates and easy access to data. The state also facilitated outreach and educational services to health care providers. Newsletters were distributed to more than 500 local professionals and information was placed on the web page the state dedicated to activities and findings at the site.

Fact sheets, pamphlets and other materials on general environmental health topics and site-specific issues were widely disseminated throughout the community. ATSDR also collaborated with the local school district to develop a comprehensive environmental health curriculum for students in grades K-12. Several grand rounds were held at the community hospital for physicians and other medical staff. One of the courses focused on pediatric oncology to address concerns by local residents about the hospital's delay in diagnosing children who developed different types of cancers. Another medical conference was targeted to school nurses.

Dr. Jerry Fagliano, of the New Jersey Department of Health, described public health activities that were jointly implemented by federal, state and local agencies and academic institutions. The approach taken in the initiative followed CDC's step-wise process for disease cluster investigations. First, an assessment should be conducted to determine whether excess disease exists. Second, a feasibility study should be implemented to examine the potential relationship between exposure and the disease cluster. Third, an etiologic investigation should be undertaken if the first two criteria are met. The public health response plan for the Toms River site did not initially include an epidemiologic study, but the state cancer registry was updated to incorporate data through 1995, reevaluate cancer statistics through 1996 and identify unusual environmental exposures. This effort was undertaken by the community group and federal, state and local health agencies.

All municipalities in the county were examined from 1979-1995 to determine the incidence of childhood cancer among children ages 0-19 years. The only area that significantly exceeded the expected number of cases in the 17-year time period was Dover Township with 90 cases. By type and gender, leukemia, brain and CNS cancers were found to be higher among females in both Dover Township and Toms River. Overall, the childhood cancer rates peaked in the area from the mid-1980s to early 1990s. In the environmental assessment, extensive chemical and radiological testing was conducted beyond the standards of the Safe Drinking Water Act. The interconnected distribution system at the site is fed by eight well fields that serve approximately 90% of the local population. A comprehensive evaluation by several laboratories led to the discovery of SAT in November 1996 and high-gross alpha radioactivity in some shallow wells.

After the elevated incidence of childhood cancer and unusual environmental exposures in the community were documented, the agencies confirmed that an epidemiologic study was warranted. Actions were taken to interrupt the known exposure pathways, but the nature, magnitude and duration of past exposures were still uncertain. In the first study, ATSDR and an expert panel peer reviewed the protocol; an Institutional Review Board approved the design; stakeholders provided input; and the draft report was examined prior to release. In the second study, interviews were conducted among 40 persons diagnosed with leukemia, brain or CNS cancers while residing in Dover Township from 1979-1996. Controls of 159 persons were matched to the cases on the basis of sex, date of birth and residence at the time of diagnosis.

Birth records of 48 persons with all types of cancers who were born in Dover Township were examined. Controls included 480 persons who were matched to the cases on the basis of sex, year of birth and mother's place residence during the year of the child's birth. The study primarily focused on whether the cases were more likely than controls to receive drinking water from a specific water source and be exposed to a particular air pollutant source. However, several other risk factors were considered as well, including proximity to target sites, tobacco smoke, diet, family medical history, parental occupational exposures, use of household chemicals, and tap water consumption and source during the pre- and postnatal periods.

For the water exposure assessment, residence data collected from parental interviews and the birth records study were compared to 420 computer models that reconstructed historic geographic patterns of environmental factors on a monthly basis from 1962-1996. Each model produced estimates for water or air variables of interest for all relevant residence locations of the study subjects, including the historic water flow and percent of water from each source. Private well use in areas of Dover Township with known groundwater contamination were monitored as well. Data that were input into the model included the system structure of well fields, tanks and pipes as well as the volume and time pattern of both pumping and water demand. The current model was calibrated and verified based on simulated and field pressure tests, while the 1962-1996 models were reconstructed with historic pipe networks, well pumping records and operational data.

For the air exposure assessment, a historic air pollutant dispersion was simulated from two sources. The models estimated the average potential for exposure to air pollutants from each source at residences of all study subjects. The time period was for each month during the mother's pregnancy and from the subject's birth to diagnosis. Information that was input into the models included hourly meteorological data as well as characteristics and emissions of the facility. The water and air models have been completed and the data have been analyzed. The interim report of the epidemiologic study released in December 1999 reported the results of non-environmental factors. The final report that will be issued in December 2001 will include environmental and parental occupational factors and all other analyses.

Mr. Reyes explained that all partners and stakeholders learned several valuable lessons during the investigation at the Toms River site. Willing participants from both public and private sectors should be sought. An equitable partnership should be established to effectively utilize expertise, mobilize support, leverage necessary resources, promote actions to be taken and sustain collaborative efforts. The perspective of all partners should be considered and respected. Goals, responsibilities and roles should be clearly defined. Innovative opportunities should be explored. Every effort should be taken to ensure the scientific credibility of site activities.

The next steps in the Toms River investigation are as follow. A public meeting will be held in the community on November 27, 2001 to present the results of the air and water distribution modeling. The findings of the Dover Township case control study will be presented on December 18, 2001. The results of the multi-state brain cancer case control study will be released in late 2002. Educational initiatives for the community and health professionals will continue in 2002.

Ms. Linda Gillick serves as the liaison between the agencies and the Toms River community. Childhood cancer is an extremely sensitive issue, but she acknowledged that the investigation resulted in both positive and negative outcomes. Based on her extensive involvement with the five-year study, she offered some guiding principles agencies and communities should consider while site activities are being implemented. An investigation should be conducted in a professional manner with mutual respect among all partners and stakeholders. Data should be fully and timely disseminated at all levels. For example, if the community asks the state agency to forward data to the federal agency, this request should be honored. The state should not withhold information or arbitrarily decide its importance.

Federal and state agencies must continually and consistently monitor the quality of drinking water in communities to reduce current exposure and prevent future health effects to local residents. For example, the Toms River water supply was used as a source to clean up contaminated sites for a long period of time. This situation is being repeated in other areas throughout the country. Water systems should be reevaluated in communities with elevated rates of cancer or other diseases even if an investigation was completed at the site. A national childhood cancer registry should be immediately established because the data will allow proactive rather than reactive measures to be taken. Disease clusters should be examined in more detail instead of relying on traditional methods. For example, Ocean County as a whole showed normal limits of childhood cancer, but Dover Township had elevated rates on a town-by-town basis.

Stronger research efforts must be made to develop standards for children. This data gap does not allow synergistic effects of chemicals detected in the Toms River water supply to be known. Overall, Ms. Gillick was extremely pleased to announce that no children in the community have been diagnosed with cancer in the current year and no cases have been detected in children less than four years of age in the past three years. This result is due to the interruption of contamination in the drinking water system. However, she strongly emphasized the need for federal agencies to allocate more funding to address health effects from chemical exposure in communities. Due to the numerous lives that have been lost in the community and the vast amount of resources expended at the site, Ms. Gillick hoped the final report would not show inconclusive results.

Discussion. Some Special Consultants (SCs) noted that ATSDR's time, focus and resources for Toms River are not equally distributed in other impacted communities. Ms. Bradshaw recalled that eight brain cancer cases were identified in a Greenwood, Mississippi community. Unlike Toms River, however, Greenwood did not have political power, agency support or a 90% white middle-class population. She noted that Greenwood and other communities throughout the country have been requesting ATSDR's assistance for a much longer period of time than the Toms Rivers residents. Ms. Stone shared this concern because ATSDR does not provide the same level of services and resources at every Superfund or NPL site.

Ms. Babich saw the necessity in ATSDR investigating the childhood cancer cluster regardless of the racial composition or socioeconomic status of Toms River. However, she pointed out that minority Superfund communities have historically received inequitable treatment by agencies. She urged ATSDR to fairly and objectively respond to health effects at all impacted sites, particularly those with no support or political power. Mr. Reyes responded to the comments as follows. The political climate was not the driving force in ATSDR's decision to review the Toms River cancer registry data and initiate a site investigation. Instead, these actions were prompted by requests from Ms. Gillick and a health care professional.

Ms. Gillick was also responsible for mobilizing policymakers to ensure the agencies were given resources to implement the study. Due to her efforts and those of other community members, ATSDR was provided with federal dollars, state resources and private funding specifically to address health effects at Toms River. Mr. Reyes confirmed that ATSDR does not conduct epidemiologic studies similar to the Toms River investigation in every community. Some sites have no known or completed exposure pathway and do not need a comprehensive long-term study. He agreed that ATSDR's attention and time decreased at some sites due to the significant amount of resources and personnel needed for the Toms River study.

Dr. Roseman returned to Ms. Gillick's concern that the final report may show inconclusive results. He inquired about actions the agencies will take to convey these types of findings to the community. Dr. Fagliano responded that the results will be honestly communicated and uncertainties, limitations or data gaps will be noted. At this point, no specific linkages have been made between environmental factors and the elevated incidence of childhood cancer in Toms River. Dr. J. Collins asked how ATSDR will apply the toxicological findings from the Toms River study. Mr. Reyes replied that in general, skills developed or enhanced during the investigation will continue to be used in other communities. In particular, the modeling data will be used to refine methods to characterize past exposure at other sites. Overall, NIEHS is not expected to release the final toxicity data on the perinatal animal studies for at least five years.

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ATSDR/NCEH Shared Vision for Environmental Public Health. Dr. Falk explained that the possibility of consolidating the two agencies has been seriously considered in a variety of settings since 1981, but the merger will not occur if two conditions are not met. First, the mission, value, support and resources for both environmental health programs must be improved, strengthened and increased. Second, the Superfund program and its partners, grantees and stakeholders must be fully protected and benefit from the consolidation. On the one hand, ATSDR and NCEH are independent and separate agencies under HHS with different abilities and limitations. ATSDR has solid toxicological expertise and no laboratory capacity, while NCEH has outstanding laboratory proficiency and a weaker focus on risk assessments, environmental sampling, site cleanup and other regulatory activities.

On the other hand, ATSDR and NCEH have and continue to engage in several joint efforts, such as site-specific activities, anthrax investigations, the Pew Environmental Tracking initiatives, and ERS services for chemical, radiological and mass trauma terrorism. Moreover, both agencies have complementary staff skills, implement asthma programs and maintain environmental health cooperative agreements with state health departments and other grantees. A combination of the agencies' internal expertise could generate more innovative products. In addition to the positive aspects, however, ATSDR realizes that logistical issues and other barriers will surface in implementing the interagency merger.

Dr. Richard Jackson, the NCEH Director, conveyed that the September 11, 2001 terrorism attacks highlighted three significant deficiencies. First, defense and public health agencies must strengthen collaborative efforts. Second, the environmental health community must reevaluate its traditionally narrow role in the broader public health arena. Third, the environmental health capacity in CDC and ATSDR is extremely limited in terms of addressing domestic and global needs. He agreed with Dr. Falk that the merger must benefit both agencies and increase resources.

NCEH's three major focus areas are: 1) epidemiology, i.e., the lead, asthma and field epidemiology programs; 2) environmental health services, i.e., the National Pharmaceutical Stockpile (NPS) and field sanitary services; and, 3) laboratory services. The exposure report card of 27 chemicals in the U.S. population was developed and distributed by the NCEH laboratory. While the capacity of the laboratory to analyze 100 different chemicals in a thimble of blood cannot be duplicated by any facility in the world, NCEH was pleased that ATSDR was able to lend its expertise in health communication and education.

After the exposure report card was released, ATSDR toxicologists participated in this activity by answering telephone calls from the public about health effects from toxic substances in the body. Public health genetics is a smaller focus area in NCEH. One of the future goals of the agency is to produce a gene report card among the U.S. population that will be similar to the exposure report card. Overall, Dr. Jackson noted that since the September 11, 2001 terrorism attacks, the importance of environmental public health has increased in the White House, HHS and state health agencies.

Mr. Michael Sage, the NCEH Associate Director for Planning, Evaluation and Legislation, reported on the status of the ATSDR/NCEH shared vision and budget issues. The purpose of the activity is for the agencies to jointly serve as a core resource at national and international levels to improve the science and practice of environmental public health. Since the May 2001 BSC meeting, ATSDR and NCEH have presented the shared vision at nine national meetings with major public health and environmental organizations. The agencies also convened meetings with key partners in an effort to advance the initiative. All partners and stakeholders agreed the shared vision is long overdue, but ATSDR and NCEH were cautioned against taking actions that would diminish either agency.

Although ATSDR and NCEH received strong external support for the shared vision, Dr. Koplan asked the agencies to advance beyond this initiative and submit a proposal for a full merger. The draft consolidation was recently presented to and endorsed by the HHS Secretary, but both agencies realize that the merger is not clearly delineated at this point. Input must be obtained from the HHS Secretary, OMB, Congress and federal partners. Nevertheless, strong efforts are being made to proceed with the consolidation to impact the January 2002 legislative cycle.

In terms of funding, significant increases will be allocated to CDC in response to the September 11, 2001 attacks. An additional $1.64 billion will be targeted to the supplemental terrorism budget, while the FY'01 base budget increased by $3.9 million. From the supplemental dollars, $500 million will be designated for smallpox vaccine development and $646 million will be allocated to the NPS budget. To strengthen emergency preparedness at the local level, $75 million of the $646 million will be set aside. CDC also expects an increase for its $30 million NCEH laboratory budget.

No decisions have been made to date in terms of allocating the remaining $500 million of the $1.64 billion supplemental dollars because several categories must be considered, including internal activities, external research, infectious diseases, occupational medicine and environmental public health programs. The FY'02 appropriations will allocate an additional $364 million to terrorism and $250 million in new funding for CDC. NCEH will receive $40 million from the $250 million; $20 million will be set aside for Pew Environmental Health Tracking activities and $20 million will be designated for the NCEH laboratory, asthma program and environmental health services. Of the $364 million terrorism dollars, NCEH will receive $60 million.

Drs. Thomas Burke and Henry Anderson serve on NAC as the chair and a member, respectively. They joined the meeting by conference call to express support for the ATSDR/NCEH merger. ATSDR was commended for its long-term efforts in supporting and building environmental health infrastructure at the state level. They acknowledged that many states would not have this capacity without ATSDR's cooperative agreements. The consolidation represents a unique opportunity for the agencies to significantly improve the environmental health field by developing a skilled pool of new environmental health professionals and training states to more effectively meet the ATSDR/NCEH needs in terms of surveillance and laboratory sciences. Drs. Burke and Anderson both expressed an interest in serving as liaison or ex officio members on the BSC; Drs. J. Collins and McDiarmid volunteered to serve in this capacity on the NAC.

Discussion. Some SCs were extremely frustrated with the significant increases for the CDC terrorism budget. Federal agencies typically cite a lack of resources as the reason for decreasing site activities. Ms. Bradshaw asked if NCEH will allocate funding to address "environmental terrorism" caused by the U.S. government in communities of color. She strongly encouraged ATSDR and CDC to view impacted communities with the same sense of urgency as the terrorism attacks and anthrax investigations. In this effort, the agencies should request specific appropriations for site activities while developing legislative proposals.

Ms. Bradshaw returned to Mr. Sage's comment that $500 million of the $1.64 billion supplemental dollars have not yet been designated. She recommended that CDC allow community members to participate in the planning process to allocate the funds. Ms. Babich conveyed that communities will no longer permit taxpayer dollars to be set aside for terrorism and other Congressional interests while severe stress, illness and death from environmental exposures continue to occur among local residents. She agreed with Ms. Bradshaw that impacted communities are under terrorist attacks from the U.S. government in general and federal agencies in particular. Ms. Babich expressed a strong interest in providing community-based advice to the agencies and serving as a true partner in addressing environmental health problems at sites. However, these efforts are extremely difficult to undertake when agencies do not use taxpayer dollars to prevent or reduce environmental disease and death among taxpayers throughout the country. She hoped to see progress in this area by the next meeting.

The agencies responded to the community concerns as follow. Mr. Sage clarified that at this point, none of the NCEH budget increases have been specifically designated for environmental justice (EJ) issues in Superfund sites or the nuclear weapons complex. During the planning process to allocate the funds, CDC will consider whether some of the terrorism dollars can improve the ability of impacted communities to address environmental health problems at the local level. Dr. Falk confirmed that ATSDR meets with Congressional subcommittees on a regular basis to discuss the Superfund budget. He acknowledged that funding for site activities has remained flat for several years, but the decision-makers were not at the BSC meeting. He welcomed suggestions about actions ATSDR could take to increase its effectiveness in Congressional interactions.

Dr. Falk agreed with Mr. Sage that the possibility exists of the agencies eventually distributing terrorism dollars more broadly throughout public health programs. Dr. Jackson remarked that since September 11, 2001, government officials are more aware of the potential for radiation or chemical terrorism to cause massive amounts of illness, death and destruction among a significant portion of the U.S. population. In light of medical care and other services needed to prepare for and respond to these types of events, his position was that the increase in the CDC bioterrorism budget was not sufficient. This fear has caused terrorism to become the top priority at the federal level, but he clarified that impacted sites are not being ignored.

Dr. Jackson announced that agencies will more aggressively provide disease tracking and surveillance services in communities. Local residents will become more empowered with data on illness rates and environmental exposures at the local level. To date, this type of information has never been provided to communities. Based on the strengths of both agencies, Dr. Roseman encouraged ATSDR and NCEH to focus on environmental testing and control studies in the merger. He questioned whether the agencies will be structurally reorganized to provide health care to communities. Dr. Falk did not believe the ATSDR/ NCEH consolidation would result in Congressional authority for the agencies to provide clinical services. However, both agencies will continue to independently collaborate with HRSA to indirectly provide health care to Superfund sites or communities with environmental health concerns.

Nevertheless, Dr. Falk saw opportunities for ATSDR and NCEH to jointly enhance the indirect medical assessment program because the consolidation will result in a stronger and more influential HHS agency. Similar to the NAC members, some BSC members were also in full support of the ATSDR/NCEH merger. Dr. J. Collins viewed the consolidation as a mechanism to improve research, while Dr. White saw an opportunity to solve problems caused by categorical funding and narrowly-defined activities at federal and state levels. Dr. White returned to the concerns raised by the SCs and reiterated that the increased terrorism budget will allow significant progress to be made in environmental public health.

Dr. McDiarmid was also in favor of the interagency merger due to the possibility of increasing resources, awareness and respect for the occupational and environmental public health fields. Since September 11, 2001, the demand for expertise in these disciplines has considerably grown. She agreed with Dr. White that the terrorism attacks present an opportunity to place a stronger emphasis on occupational and environmental concerns in minority communities and impacted sites. Dr. McDiarmid urged ATSDR and NCEH to use the increased terrorism budget and interagency merger to underscore the need for occupational and environmental public health professionals. Expertise that has been provided to Superfund and occupational disasters can be highlighted as models.

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Public Comment Period. Ms. Bradshaw conveyed that some public health assessors cause mistrust and other problems to occur in communities. For example, Dr. John Crellan of ATSDR stated in a newspaper article that the data do not prove harm to Memphis Depot residents. However, this finding does not support the high rates of cancer, heart disease and diabetes in the community. She submitted Matter of Trust into the record; the article is attached to the minutes as Exhibit 1.

Ms. Isis Bradshaw, of Youth Terminating Pollution, mentioned that ATSDR's inconclusive results are not consistent with the reality in the Memphis Depot community. Chemicals have been dumped in a ditch that flows under a local school, but parents are not formally notified about the strong smell or the potential for health effects. Some female students as young as 13 years of age have experienced reproductive problems and had breast cysts removed. Ms. Bradshaw was extremely frustrated that the polluter has not been held accountable by being forced to clean up the site or respond to community concerns.

Ms. Cheryl Smith, of Youth Terminating Pollution, had firsthand knowledge that exposure to hazardous substances are causing harm to the Memphis Depot community. She explained that she is a local resident who was diagnosed with uterine cancer at 14 years of age. Ms. Stone encouraged the agencies to read Toxic Release and consider using the book as an educational or training tool for impacted residents during site activities. The book points out that pollutants and toxic substances in the environment are absorbed into lymphatic nodes, tissues and cells of the human body. The book also offers information to assist individuals in releasing toxins. Ms. Stone agreed with the Memphis Depot residents that the burden of proving health effects from contaminants is always placed on impacted communities.

Ms. Rondon-Manuelito urged the agencies to address health concerns in tribal communities near uranium mines. Several children at these sites have been born with peripheral neuropathy. Mr. Sage asked Ms. Rondon-Manuelito to provide him with her contact information for follow-up by the NCEH Chemical Demilitarization Branch.

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BSC Open Discussion. Dr. Sorber opened the floor for the BSC to deliberate on any of the preceding agenda items. Ms. Stone inquired about tangible benefits Superfund sites can expect to receive from the interagency consolidation. Dr. Falk replied that ATSDR would have more access to the NCEH laboratory for faster analysis of environmental sampling data collected in communities. Additional staff would also be available on a more regular basis to conduct site activities.

Ms. Bradshaw urged the agencies to incorporate EJ issues while defining programs and allocating funds for the merger. In terms of outstanding activities, she reported that Drs. Mark Bashor and Rueben Warren of ATSDR were heavily involved with issues related to federal facilities in 2000. However, no further action has been taken in this effort since the change in Administration in January 2001. Dr. Falk announced that similar to the new Superfund budget process, attempts are being made to develop a mechanism for the federal facilities budget. ATSDR would be able to make its case directly to Congress and OMB instead of relying on the Department of Defense (DoD) and Department of Energy to present the federal facilities budget request. Dr. Falk plans to schedule a meeting with new DoD personnel in the near future.

In general, he conveyed that ATSDR is now in a vulnerable position because all of its programs, products and services rely on Superfund, but the program was not designed to last indefinitely. As a result, actions must be taken to strengthen ATSDR with the merger, independent funding streams and solid partnerships at the federal level. Dr. McDiarmid agreed that the interagency merger and recent activities in the terrorism attacks and anthrax investigations should be used as opportunities to increase ATSDR's visibility. In this effort, ATSDR should use "biochemical" instead of "bioterrorism" to clearly define its role. This word may have future repercussions for ATSDR because the public associates bioterrorism only with CDC.

Dr. Falk agreed that "bioterrorism" places more emphasis on CDC's infectious diseases program and poorly describes ATSDR's role. However, the word has been adopted by Congress as the standard for these types of activities. ATSDR's previous proposals for other terms were rejected, but Dr. Koplan now acknowledges the need to have a separate focus on chemical and radiological events. Dr. M. Collins requested more details on ATSDR's new subcommittee with state partners. Dr. Falk explained that the initiative is another effort to strengthen ATSDR since many of its activities are conducted by state and local health departments. The new subcommittee will provide a forum for SCs and other members of the public to raise site-specific concerns directly with state or local representatives and engage in an ongoing dialogue. The members of the subcommittee will be ATSDR grantees.

Dr. Spengler summarized the action items and recommendations that were raised during the meeting. The items were placed for a formal vote, unanimously approved and are outlined in "BSC Business."

There being no further discussion, Dr. Sorber recessed the BSC meeting at 4:54 p.m. on November 15, 2001.

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CTS Report. Dr. Sorber reconvened the BSC meeting at 8:45 a.m. on November 16, 2001 and yielded the floor to the first presenter. Dr. Au, the CTS Chair, reminded the BSC that the task force concept was introduced during the November 2000 meeting. The process was developed to address specific issues with a concentrated strategy and enhance the focus and productivity of the CTS. He yielded the floor for the annual reports of the first three task force issues.

Dr. M. Collins, the Task Force 1 Chair, listed recommendations "to improve cultural sensitivity training of ATSDR staff."

· ATSDR should refine and expand the cultural sensitivity tapes to incorporate other topics, such as institutional racism, bias, privilege, cultural competency, class issues and diversity. Asian/Pacific Islander and Alaska Native populations are not well represented.

· ATSDR should explore collaborative efforts with the U.S. Army, YMCA, DoD and other organizations that use a team approach or provide community-based and tribal-specific cultural sensitivity training.

· ATSDR should provide cultural sensitivity training to health assessors or the first point of contact in communities. Onsite personnel in EPA and other agencies should be encouraged to participate in the training session as well.

· ATSDR should redesign its communication strategy during community presentations and other site activities. Health assessors and other staff can take several actions in this regard. Refrain from making statements that are insensitive or not scientifically-based, such as "no harm has been done." Do not show fear during site activities. Ensure that presenters have strong communication skills because some information can have a negative impact on local residents. Present all data instead of only sharing information communities "need to know."

· ATSDR should provide an opportunity for community-based technical experts and impacted communities to evaluate PHAs and assess data before documents are finalized and released to the public. ATSDR should inform communities about the evaluation form that is included in PHAs, describe expected outcomes and explain the impact of the form on the overall process. ATSDR should ensure that responses are provided to persons who submit the evaluation form.

· ATSDR should outline all aspects of the PHA process in a variety of mechanisms, such as quarterly newsletters to communities, the "Brown Book" and public hearings. The requirement for citizens to submit public comments in writing should be emphasized. Guidance about the PHA process should be clearly written and understandable to local residents.

· ATSDR should open CTS proceedings to other community groups and widely publicize upcoming meetings in newspapers.

· ATSDR should educate communities about the process to request further testing and sampling.

· ATSDR should record public meetings and include comments from local residents in PHAs.

· ATSDR should automatically distribute PHAs or provide access to the document to all members of the impacted community. Churches, libraries and schools can be engaged in circulating PHAs throughout the community. The documents can also be placed on the Internet and CD-ROM.

Dr. Sorber, the Task Force 2 Chair, listed recommendations "to improve and engage communities with disenfranchised groups."

· ATSDR should define "communities" and "impacted sites" by identifying the target area, impacted community, local affected residents, at-risk individuals, relocated families and other target groups. Tools that can be used in this effort include surveys, citizen participation plans, blind health data pools, diverse community groups, public service announcements and community open houses.

· ATSDR should develop mechanisms to obtain a fair representation of viewpoints, involve community organizations that reside at sites, and use citizen participation initiatives to engage residents who are less outspoken or active than others. Several approaches can be taken in this effort. Identify existing groups and resources in the community. Open public comment periods or develop other citizen participation plans. Build alliances to strengthen trust and ensure viewpoints are equally articulated.

· ATSDR should collaborate with disparate groups to design a constructive and objective process in which collaboration is strengthened; capacity is built; and ATSDR's role, capacities, services and limitations are clearly and accurately communicated. Several strategies can be taken in this effort. Provide capacity-building services for local target groups. Educate or train community leaders, local government officials, church leaders, educators and trainers. Develop and distribute a catalog or tool box that describes grant sources and other available resources for community groups to use. Meet with local residents individually and community groups collectively. Provide conflict resolution training and assistance.

· ATSDR should address the needs of residents who have been excessively exposed to toxic agents. Several approaches can be taken in this effort. Support efforts to establish multi-disciplinary environmental health care teams with resources in the community. Explain existing tools that are available to ATSDR. Provide information about available environmental health care resources. Facilitate the provision of health care for impacted communities and individuals. Develop a relocation policy for health-impacted persons. Serve as an advocate for impacted individuals and communities in terms of relocation, compensation and similar services.

· ATSDR should encourage community and tribal participation in APHER. Several strategies can be taken in this effort. Collaborate with communities and tribes to create a comprehensive list of sites with exposure pathways. Identify resources ATSDR has provided to communities and those that are required from any source.

Ms. Babich, a Task Force 3 member, listed recommendations "to communicate toxicology and public health information." Ms. Brandy Tomhave, of the Tribal Association for Solid Waste Emergency Response, participated in the group discussion and assisted Ms. Babich in the presentation.

· ATSDR should develop and distribute educational materials that are written at a maximum sixth-grade reading level, accompanied by illustrations as often as possible, and considers all members of the affected community, such as those with seeing or hearing impairments.

· ATSDR should disseminate toxicological data that are understandable and precise. This information should include a glossary, standalone executive summary and time-line of site-specific activities. Fully defined words rather than acronyms should be used as well.

· ATSDR should address toxicity problems to communities and affected individuals on a site-specific basis by testing all exposure pathways and identifying duration of residence, subsistence lifestyles, cultural activities and vulnerable populations.

· ATSDR should explain methods for communities to efficiently interact with the Agency by providing information on ATSDR's structure, function, process and relationships with other agencies at federal, state and local levels.

· ATSDR should develop an onsite mobile response team with state health departments and other site-specific experts at initial entry into the community and throughout the process.

Dr. Au reported that the CTS agreed the Task Force 2 and 3 charges were fulfilled. Consensus was reached to sunset both groups and three new topics were proposed. First, evaluate recent PHAs to determine compliance with ATSDR's improved process and previous CTS recommendations for PHAs. Consideration to be given to reviewing the Fort Ord, Kelly AFB, Memphis Depot, Mossville and Vieques PHAs. Second, provide a catalog or tool box of ATSDR resources that are available to communities. Third, improve the CTS process with respect to meeting agendas and discussion items. Dr. Au reviewed the recommendations and action items that were raised during the November 2001 CTS meeting.

· ATSDR to have more oversight at Superfund sites with incineration operation by developing a check and balance system for public health issues.
· ATSDR to more actively participate in the public health aspects of alternative hazardous waste treatment technologies, such as an evaluation of health risks with biomarkers or other laboratory techniques.
· ATSDR to postpone the release of its thermal treatment guidance document until alternate technologies for waste disposal can be incorporated.
· ATSDR to ensure that human subjects know risks, anticipate benefits and provide informed consent before participating in site activities.
· ATSDR to involve community members in developing PHAs, provide a fair process and report progress in a timely manner.
· ATSDR to incorporate the Precautionary Principle of "better safe than sorry" in protecting public health and conducting PHAs.
· ATSDR to become a partner in the Academic Institutions, Communities and Agencies Network (ACA-NET) by contributing expertise and resources throughout the Agency.
· ATSDR to be more responsive to public comments and increase participation in CTS meetings by senior-level staff in the four divisions.

Dr. Spengler announced that an annual review of the CTS was discussed at a previous meeting. Since that time, the evaluation process was drafted and presented to Dr. Falk, the Senior Executive Management Forum, and the CTS and BSC Chairs. During the November 2001 CTS meeting, the draft was distributed for comment and review. After modifications were suggested, the activity was endorsed by the SCs and formally approved by the CTS. The purposes of the evaluation are to review the progress, accomplishments, effectiveness and impact of the CTS; identify major areas for improvement; characterize outstanding issues for communities and tribes; and assess the continued need for the CTS or identify an alternative approach for ATSDR to obtain community and tribal involvement.

Dr. Spengler and an ad hoc Evaluation Workgroup (EWG) would further develop criteria for the evaluation. An independent evaluation contractor will be selected to collect data from CTS documents and surveys of former and current CTS members, SCs and ATSDR staff. The EWG would present the evaluation findings and recommendations to the CTS and BSC. Based on these results, the BSC would make recommendations to ATSDR. The evaluation is expected to be completed within the next 12 months; a follow-up report would be made during the May 2003 BSC meeting.

Discussion. Dr. Bennett offered to share the task force reports with the EPA Community Outreach Center to improve the effectiveness of the agency's interactions with impacted residents. Dr. Roseman noted that the U.S. government is planning to place large incinerators in several locations. He strongly encouraged ATSDR to use this opportunity to monitor the communities pre- and post-exposure to identify potential health effects or biological changes.

Dr. Bowler added that neurobehavioral testing in populations near incinerators would allow ATSDR to collect baseline data and gather more accurate normative data before potential harm from exposure occurs. She offered to assist ATSDR in this effort. Dr. Sorber entertained a motion to approve the CTS recommendations for submission to ATSDR. A motion was placed on the floor and seconded. Dr. Harris conveyed that some of the CTS recommendations have been reiterated for several years in a variety of settings. The possibility of different interpretations causing items not to be implemented was extensively discussed during the CTS meeting. As a result, ATSDR made a commitment to e-mail its interpretation of recommendations to the CTS and SCs two weeks after meetings. With this process, ATSDR will not take action on an item before the CTS and SCs provide clarification or agree that ATSDR's understanding is correct. There being no further discussion, the November 2001 CTS recommendations were unanimously approved by the BSC for submission to ATSDR.

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ATSDR's Recent Site Activities

Vieques, Puerto Rico. Dr. Gary Campbell reported that ATSDR's 17-member core site team included physicians, health education specialists, technical personnel and community involvement specialists; four staff members who speak Spanish. The U.S. Navy has been conducting training activities and bombing exercises on Vieques since the 1950s, but three events in the late 1990s increased concerns about the island. In November 1997, cancer incidence data collected from 1960 to 1994 were released by the Puerto Rico Department of Health. The report showed a 26% higher rate of combined cancers on Vieques compared to the remainder of Puerto Rico. In February 1999, the use of depleted uranium ammunition on a live impact area was unauthorized. Of the 263 rounds that were fired, the Nuclear Regulatory Commission only found 50; five of the 50 rounds disintegrated into the soil.

In April 1999, a training accident occurred at the Navy observation tower that resulted in the death of a Puerto Rican civilian. Three political parties representing the state, commonwealth and an independent group became involved in these events. To address concerns, Puerto Rico officials asked the United States in May 1999 to halt training exercises on Vieques to determine the cause of the accident. Protestors who established camps on the bombing range in May 1999 remained in the live impact area for over a year. In December 2000, the U.S. President and Puerto Rico Governor agreed to restart training exercises with the following conditions. First, inert weapons rather than live ordinances would only be used. Second, the U.S. government would provide $40 million for health care and infrastructure development in Vieques.

Third, residents would decide through a referendum vote whether the Navy should vacate the island in 2003 or continue live-fire exercises. Fourth, the U.S. government would provide an additional $50 million to Vieques if live-fire exercises continued after 2003. In 2001, the new governor of Puerto Rico initiated steps to force the Navy to immediately vacate Vieques. In addition to several U.S. Congressional members, four community-based groups and a host of media outlets also became interested in the governor's efforts. ATSDR first visited the island in August 1999 due to a petition from a local resident. The site team was extremely disturbed about health effects and exposures to unexploded ordinances among children and other protesters living on the bombing range.

To express concerns about public health in general and dangers to the protesters in particular, ATSDR sent letters to several high-level officials, including the White House Commission, the Puerto Rican Government Commission, the U.S. Navy and EPA. During the PHA process, ATSDR collected sampling data, gathered health concerns, evaluated pathways, conducted community outreach activities, and provided health education and training to doctors and nurses. Information was also collected from government regulatory agencies, DoD, Puerto Rican medical libraries, researchers, local agencies and residents. The site team met or toured the island with the petitioner, physicians and nurses organizations, community-based groups and other local residents. The extensive community involvement efforts were undertaken because Vieques residents did not trust data from the Navy. However, the site team still encountered opposition because activists prevented some local residents from speaking to ATSDR.

The drinking water data and groundwater assessment showed that well water on Vieques is slightly salty, but is safe to drink. Based on a comprehensive geological survey, ATSDR is confident that contaminants from the bombing range cannot reach the groundwater, aquifer or other drinking sources in the community. To conduct the soil pathway assessment, ATSDR took soil samples from the bombing range, residential areas and other locations on the island. The data showed that the chemical and metal levels in soil were too low to cause health effects in adults or children. For the air assessment, ATSDR took samples of wind blown dust and contaminants during inert bombing days, live ordinance use and other training exercises. To evaluate the food chain, ATSDR obtained input from community members about their diets, analyzed species and examined sampling locations to detect explosives and metals.

Dr. Edwin Kilbourne announced that ATSDR and the Ponce School of Medicine in Puerto Rico jointly released results from the heart disease study review panel on October 23, 2001. An international peer review panel was selected to evaluate the original data, while the Mayo Clinic was contracted to reread the original echocardiograms. ATSDR and Ponce reached consensus on the eight-member panel of physicians and scientists. Four peer reviewers were from the U.S. and four were from Spanish speaking countries. Ponce also selected the Mayo Clinic to reread the echocardiograms.

The PHA results and heart study findings were presented to Vieques residents during a public availability session. The assessments for drinking water, groundwater and soil are complete, while the air and food chain evaluations are ongoing. The heart study data showed that all subjects had normal pericardial thickness of less than 2 mm. The difference was found to be too small to be clinically significant. By Mayo measurements, no differences were seen between the Vieques population and the control group. The reliability of inter-observers and intra-observers as well as the correlation between the Mayo and Ponce measurements was poor. The resolution limit of 1 mm in the echocardiogram was not precise enough to measure a 0.15 mm difference. The review panel concluded that a continued focus on the heart study would be unproductive and unfavorable to the health of local residents.

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Fallon, Nevada. Dr. Wendy Kaye reported that the demographics of the site include a population of 8,300 persons who are primarily white, 8% Hispanic, middle- to low-income, and mainly employed in the agricultural industry or by the Fallon Naval Air Station. The state health department initially investigated a cluster of leukemia cases in the community in July 2000, but ATSDR and NCEH were later asked to provide assistance in responding to specific advice from an expert panel. The recommendations were to conduct a cross-sectional exposure assessment by collecting and storing environmental and biological samples; investigate environmental pathways for human exposure in the entire county of 24,000 residents; implement community involvement activities; research the literature to update the jet fuel toxicological profile; design a community stress intervention; and assist in developing communication plans and strategies.

For the community stress intervention, ATSDR and the state conducted a needs assessment, established a response team, trained health care and social services personnel, and planned for future needs. To address community concerns, ATSDR initiated a PHA to evaluate pathways related to arsenic in the drinking water, industrial sources, jet fuel, pesticides, ditch burns and floods. Environmental data were gathered from several sources at federal, state and local levels. In the future, information will also be collected from the NCEH cross-sectional study, modeling data and air samples. When these efforts are complete, ATSDR hopes to examine the cases for linkages to past and present exposures. Other concerns in the community include radionuclides, population mixing from a virus, electromagnetic radiation and problems with milk from dairy farms.

Dr. Carol Rubin of NCEH explained that from 1995-2001, the number of childhood leukemia cases in the county were significantly greater than would be expected in an area with only 24,000 residents. In conducting the study, the state asked the agencies to particularly focus on whether children with leukemia were different from their immediate family or other children of the same age in terms of genetic risk factors, infectious diseases or chemical, radioactive or infectious exposures. Data sources included biological samples, questionnaires and samples from past and present residences of the 14 cases, their parents and siblings.

Each case was matched with four controls on the basis of year of birth and gender. The same data collected from the cases were also gathered from all control and their families. None of the cases were Native American children, but tribal leaders in Fallon were actively engaged throughout the entire process and attended each public meeting. After identifying and selecting the 56 controls by random digit dialing throughout the entire county, NCEH distributed personalized information packets with consent forms and questionnaires; assigned unique identification numbers for the study; and made appointments with the participants for interviews and sample collection. Due to the random digit dialing process, some Native Americans were selected as controls. The questionnaire was designed to obtain basic information that was consistent with the three study questions, but the interviews were more detailed.

Participants were asked to provide information on pregnancy history, nutrition, occupational history, recent exposures, medical history, water or pesticide use and residential history. NCEH then began the more complex process of analyzing blood and urine samples to detect heavy metals, VOCs, PCBs, viruses, DNA, radioactive elements and non-persistent pesticides. NCEH expects to generate the laboratory results by the end of February 2002 and report the findings to local residents by the summer of 2002. The Fallon site is a model of extensive community participation and a comprehensive ATSDR/NCEH collaborative effort.

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Libby, Montana. Dr. Lucy Peipins reported on the medical testing ATSDR conducted among 6,149 persons at the site from July-November 2000. The objectives of the analysis were to identify potential asbestos-related illnesses among residents and former workers; describe or characterize exposure pathways; and examine relationships between exposures and identified health outcomes. Eligible participants of the screening program included former workers and contractors of W.R. Grace, household contacts of workers, and persons who lived, worked or played in the Libby area for at least six months prior to December 31, 1990. Study data were obtained from three sources. In a standard face-to-face questionnaire, participants were asked to provide information on demographics, medical, residential and occupational history, reported symptoms, illnesses, chest surgeries and other injuries.

Chest radiographs were taken on participants age 18 years and older, but pulmonary function tests were administered to all subjects. The chest radiographs consisted of three x-rays to identify changes, pleural or interstitial abnormalities in the lung and lining of the lung. The x-rays were then evaluated by three certified B-readers; a positive result was defined as the same result from two of the three readers. Lung function was based on three measurements from two spirometry tests: amount of air exhaled in one second, forced volume regardless of time and a ratio of the two measures. The test results were compared with normative data from a healthy population, while rates of pleural and interstitial abnormalities and lung function restrictions were controlled for exposure pathways and other risk factors.

Statistical modeling was also conducted to evaluate the relationship between abnormalities and exposure pathways. Of the 6,149 volunteers who participated in the asbestos medical testing program, 49% were male, 75% were 18-65 years of age, 74% lived in Libby for 15 years or more, 66% were overweight and 50% were current or former smokers. The major categories of contact with asbestos among Libby residents were from occupational exposure, household contact with a former Grace worker, use of vermiculite or asbestos products and recreational activities. However, 40% of the population had six or more potential exposure pathways. Chest radiographs showed that nearly 18% of 5,590 subjects 18 years and older had pleural abnormalities from the major exposure pathways, but the rate increased to 48% among former Grace workers.

Pleural abnormalities among U.S. populations not exposed to asbestos range from .2%-2.5%. Only 1% of the 5,590 subjects had interstitial abnormalities, but the rate again increased among former Grace workers. ATSDR considered factors other than exposure pathways as contributors to the high incidence of pleural abnormalities, such as older male, current or former smoker, obesity and residence in Libby for 35 or more years. To identify the most relevant exposure pathways and risk factors, ATSDR designed a multi-variable model that considered all 18 pathways, age, sex, body mass index, duration of residence and smoking history.

The analysis demonstrated that the risk of pleural abnormality is nearly eight times greater for former Grace workers than non-Grace workers of the same age; three times greater for females with household contacts to Grace workers than those with no contacts; and five times greater for men than women. The pulmonary function tests showed that 2.2% of men and 1.6% of women age 18 years and older had moderate to severe breathing restrictions. The strongest risk factors for this health effect were current smoker, former Grace worker exposed to vermiculite, history of chest surgery and overweight.

Ms. Sharon Campolucci described the next steps in the Libby investigation. ATSDR is in the process of distributing the screening results to the additional 1,158 participants who were tested in summer 2001. By spring 2002, ATSDR plans to combine and analyze data from the 2000 and 2001 subjects. The analysis of asbestos-related mortality is being updated; a registry of former workers is being developed to more effectively monitor morbidity and mortality; and a case series study is being implemented on the first 21 persons diagnosed with asbestos-related disease.

Discussion. Ms. Bradshaw visited Vieques in August 2001. Based on her discussions with local residents, fears or concerns were more directed to cancer, kidney failure and reproductive effects than heart problems. She mentioned that cultural differences were the primary reason ATSDR received opposition in the community. She was not surprised by ATSDR's typical response that the chemical and metal levels in soil were too low to cause health effects to adults and children on the island. However, she was amazed that ATSDR could publish this result with confidence, particularly since health effects from chemicals or metals vary among different persons and synergistic outcomes are a significant area of uncertainty. Ms. Bradshaw mentioned that ATSDR should have sought specific input from the SCs in refining its community entry process in Vieques.

Dr. Falk clarified that cultural differences played no role in ATSDR's opposition with some segments of the community. Indeed, the site team's outreach and communication activities with cultural groups in Puerto Rico were extremely successful. Problems only surfaced when activists made strong attempts to prevent local residents from speaking with the site team. In some cases, ATSDR staff were actually threatened with physical harm and needed police escorts. Dr. Falk commended the site team for conducting activities under these conditions. He added that some activists declined ATSDR's offers to meet.

Ms. Babich also acknowledged the perseverance of ATSDR staff in continuing the Vieques investigation. Her position was that the activists should have never resorted to violent threats to express opposition to ATSDR's involvement at the site. Dr. Campbell clarified that health effects are a minor issue among Vieques residents. The community is primarily concerned with forcing the Navy to immediately leave the island. Ms. Maria Teran-MacIver also served on the Vieques site team. She agreed with Ms. Bradshaw that ATSDR should have used its existing resources. To avoid repeating this error in the future, she encouraged the SCs to provide guidance on improving the community entry process. In terms of the other health effects Ms. Bradshaw described, Ms. Teran-MacIver reported that ATSDR developed a cancer fact sheet in Spanish specifically for Vieques residents.

Drs. Au, Bennett and Roseman acknowledged that a childhood cancer cluster is an extremely important and complex issue. They were concerned that ATSDR and NCEH placed a heavy emphasis on genetics and a small sample size in the Fallon study. Genetics is an area of science that still has a great degree of uncertainty and other data gaps. Dr. Rubin agreed that these factors limit the power of the study, but the agencies are receiving guidance from a panel of genetic experts. She reiterated that the majority of the samples will be stored for future use after more data gaps have been filled and scientific questions have been answered. Dr. Bennett was impressed with ATSDR's outstanding accomplishments in all three sites. He recognized the difficulty in balancing the need to address concerns from a variety of stakeholders and generating studies with a high level of scientific credibility.

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Public Comment Period. The Acting Chair opened the floor for public comments; no attendees responded.

BSC Business. The action items and recommendations raised during the meeting were reviewed by the BSC and are outlined below. All recommendations were placed for a formal vote and unanimously approved by the BSC.

Action Items/Recommendations
· ATSDR to use the citation index to monitor its publications, obtain input, determine the level of recognition among the scientific community and evaluate impact.
· ATSDR to consider private academic institutions as eligible applicants for APHER funding.
· ATSDR to ensure that its strong commitment to children's environmental health in general and the Pediatric Environmental Health Speciality Units in particular will not decrease due to involvement in terrorism activities.
· The Executive Secretary to distribute to the BSC CDC's anthrax materials targeted to physicians and inform CDC that the data were not widely publicized or easily accessible.
· The Executive Secretary to distribute the final report of the Toms River investigation to the BSC and SCs upon publication.
· The Executive Secretary to distribute to the BSC and SCs information on ATSDR's authorizing and appropriations committees and the relationship of these groups to the Agency.
· The Executive Secretary to distribute to the BSC and SCs the updated version of the ATSDR/NCEH Shared Vision for Environmental Public Health.
· ATSDR to review the DDT data collected at the Del Amo/Montrose site to identify discrepancies between reports by the state and an independent expert.
· ATSDR to ensure that occupational and environmental public health receive an equal amount of attention as infectious diseases.
· ATSDR to become more aggressive in showcasing its expertise to serve as the lead HHS agency for risk communication activities.
· ATSDR to establish a BSC/NAC workgroup to discuss the interagency merger, identify strengths and weaknesses, and formulate strategies to overcome barriers and present to a joint meeting of both advisory bodies.
· ATSDR to resume the federal facilities activities that were initiated in 2000 by Drs. Bashor and Warren.
· ATSDR to ensure that public health staff are trained to be culturally competent and sensitive.
· ATSDR to suggest to NCEH that communities be involved in selecting the next series of chemicals to be profiled in the exposure report card.
· The BSC to recommend funding sources, physician groups, medical societies and other public or private sector partners to widely publicize ERS services and strengthen capacity to respond to chemical, radiological or mass trauma events.
· The BSC to select two or three members to collaborate with the Executive Secretary in developing a mechanism to evaluate the effectiveness and implementation of BSC recommendations. These members and two SCs to serve on the EWG for the CTS evaluation process.
· The Executive Secretary to distribute materials on ACA-NET to the BSC.
· The BSC Chair to select a member to replace Dr. M. Collins on the CTS.

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Agenda Items
· Update on ATSDR's strategic plan.
· Progress report by the Division of Health Education and Promotion on cultural sensitivity training.
· Repeat of the hazardous waste incineration presentation made during the July 2001 CTS meeting.
· Repeat of the presentation on the Division of Toxicology mixtures program, including antagonistic and synergistic effects.

Closing Session. The next BSC meeting will be held on May 2-3, 2002; the following meeting is tentatively scheduled for November 21-22, 2002. There being no further discussion, Dr. Sorber adjourned the BSC meeting at 12:24 p.m. on November 16, 2001.

I hereby certify that to the best of my knowledge, the foregoing Minutes of the proceedings are accurate and complete.

Dr. Charles Sorber
Board of Scientific Counselors Acting Chair

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This page last updated on June 13, 2002

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