|
|
Search | Index | Home | Glossary | Contact Us |
|
|
|
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 or the Board). The proceedings were held at the Marriott Century Center Hotel in Atlanta, Georgia on May 3-4, 2001. The following individuals were present to contribute to the discussion.
BSC MembersOpening Session. Dr. James Melius, the BSC Chair, called the meeting to order at 8:36 a.m. on May 3, 2001. He welcomed the attendees to the proceedings and opened the floor for introductions. He announced that the agenda had been changed to allow for an additional public comment period during the morning session of the meeting.
Review of the Minutes. Dr. Melius entertained a motion to approve the minutes from the previous meeting. Dr. Harris so moved; Dr. Sorber seconded the motion. There being no changes or further discussion, the November 30-December 1, 2000 BSC Meeting Minutes were unanimously approved.
Review of Current Action Items. Dr. Robert Spengler, the BSC Executive Secretary, provided a status report on action items that were raised during the previous meeting.Dr. Au strongly encouraged ATSDR to continue to produce as many peer reviewed publications as possible because these data can have a positive impact on communities and tribes. The materials also reflect the broader scientific community's endorsement of the Agency's products. He advised ATSDR to compile data for peer reviewed publications or case reports. Dr. Henry Falk, the ATSDR Assistant Administrator, announced that he and Dr. Spengler issued an Agency-wide statement to encourage staff members to publish results. Supervisors were also asked to allow personnel sufficient time to engage in this effort.
TopStrategic Plan. The activity is on schedule and is still expected to be completed later in the year; the implementation phase will begin in 2002. Input was solicited from a wide range of sources, including the BSC, CTS, tate health departments, ATSDR staff and the U.S. Environmental Protection Agency (EPA). The proposed vision, mission and goals for ATSDR will be presented to the Board during the meeting for review and comment.
APHER. ATSDR was unable to obtain more substantive funding for the research agenda in FY'01, but $300,000 have been identified in the budget for FY'02 APHER pilot projects. The Agency will continue to propose new initiatives in the future in an effort to secure $10 million over the next six years. ATSDR will proceed with the implementation phase in FY'01 and use this opportunity to leverage external funding sources or link its existing activities with other resources.
An issue has been repeatedly raised that APHER will duplicate existing research efforts under Superfund legislation by the National Institute for Environmental Health Sciences (NIEHS). However, activities by NIEHS in this field focus on basic research, such as molecular changes and remediation. ATSDR's research initiatives will focus on applied research by assessing exposures and evaluating health effects. To successfully deliver these and other products, the Agency must conduct research to improve the quality of its services at sites.
Drs. Falk, Spengler and other high-level ATSDR officials recently met with NIEHS senior staff members to ensure that the distinction between the two research agendas was clearly understood. During the meeting, ATSDR also emphasized the need for the agencies to closely collaborate, particularly on areas related to biomarkers and new health effects tests. To facilitate this partnership, ATSDR plans to convene additional meetings with NIEHS and its grantees to describe ongoing activities, needs and barriers that are specific to the Agency.
As an initial step in strengthening linkages between the two agencies, ATSDR will hold a strategic planning consultation with NIEHS senior staff members later in the year. The Agency will place emphasis on NIEHS funding targeted to community-based activities, informatics and the research agenda. Dr. Falk also defined APHER as an applied research agenda during recent Congressional testimony. ATSDR's efforts to more closely collaborate with EPA and NIEHS were highlighted as well.
Budget. In the FY'00 appropriations language, the Veterans Administration, U.S. Housing and Urban Development and Independent Agency Subcommittee (the Subcommittee) requested separate budget accounts for ATSDR and NIEHS. Under this directive, ATSDR must now make its budget presentation to the Office of Management and Budget (OMB) through HHS. The new process has increased the Agency's visibility in HHS and allows ATSDR to interact with the health component of OMB rather than the environmental division. For the first time, the Agency was asked to make an oral presentation to the House Subcommittee; written testimony will be submitted to the Senate.
From FY'98-FY'01, the President's budget for ATSDR remained flat at $64 million, but $78 million have been proposed for FY'02. This figure represents a $3.5 million increase over the FY'01 appropriation of $75 million. Although the separate budget account will be beneficial for the Agency, the vast majority of the HHS budget will be allocated to the National Institutes of Health (NIH). The agency has been placed in a special category due to the new Administration's commitment to doubling the NIH budget over the next five years. The appropriation will leave only a small amount of funding for other HHS agencies.
Pew Commission. The group's tracking report called for more active surveillance of chronic and environmentally-related diseases. This recommendation is consistent with ATSDR's mandate to establish and maintain a national registry of serious diseases and illnesses. However, the Agency realizes that its "disease registry" component is not fully developed and more attention should be paid in this area. Since Congress requested that the Centers for Disease Control and Prevention (CDC) respond to the Pew report, ATSDR is actively engaged with the agency in this initiative. A joint ATSDR/CDC committee was formed to address recommendations in the Pew report. The Commission completed its charge in December 2000 and has now dissolved. A more detailed presentation on this activity is scheduled on the agenda.
ATSDR/NCEH Shared Vision of Environmental Public Health. A joint meeting with the BSC and NCEH Advisory Committee will be convened in November 2001 to further discuss the shared vision. An interagency workgroup has been established. The draft report of the shared vision that was submitted to the ATSDR Administrator/CDC Director in December 2000 will be distributed to the BSC during the meeting for review and comment. The agencies have identified five projects for initial coordination. A more detailed presentation on this activity is scheduled on the agenda.
Superfund. ATSDR has learned that the legislation will not be reauthorized in FY'01, but the authorizing committees are considering the possibility of revising Brownfields. Legislation unanimously passed in the Senate for the "Brownfields Revitalization and Environmental Restoration Act of 2001." Similar legislation is not in the House at this time. The language proposes grant funds to monitor the health of populations, but specific agencies were not identified to conduct activities. EPA would undoubtedly take the lead in the legislation, but ATSDR hopes to play a role as well. With this involvement, ATSDR would receive Brownfields authorization for the first time. ATSDR currently receives no funding to provide guidance and technical assistance on Brownfields sites to state and local health departments.
PHS Authorities. ATSDR is continuing its effort to obtain authority under the PHS Act. This process would strengthen ATSDR's long-term growth more so than its current Superfund authorities. However, HHS has informed ATSDR that an HHS appropriation must first be secured before HHS authorities will be granted.
Site Activities. A list of 20 sites of high public interest was distributed to the Board. The potential population, contaminants of concern, ATSDR's activities, and current status were described for each area. The BSC was asked to pay particular attention to American University, DC and Fallon, Nevada. These two sites were added to the list after the last meeting. At the Libby, Montana site, W.R. Grace recently declared bankruptcy. The company is the responsible party for tremolite asbestos detected in the area. ATSDR examined more than 6,000 residents last year, but the community requested that the Agency return to the site and complete the medical testing. In response, ATSDR will reestablish the clinic later in the year.
The mortality study showed high risks of asbestosis and mesothelioma; the case identification study is currently being implemented; and a broader epidemiologic study is planned for the future. ATSDR and EPA are focusing efforts on 200-300 other sites in the country where vermiculite was shipped from Libby for reprocessing. This activity is being undertaken to determine if any of these communities were substantively exposed. The agencies are also in the process of establishing a registry of former W.R. Grace employees for long-term monitoring. The registry may be expanded in the future to include populations other than workers.
In Vieques, Puerto Rico, political complexities continue to present a major barrier to ATSDR responding to the site petition. Health assessments are being conducted in the area to determine if the groundwater or another pathway is contaminated by chemicals from munitions. A heart study that was recently completed at a local medical school showed pericardial thickening, but ATSDR has faced challenges in peer reviewing these unpublished data. Nevertheless, the Agency arranged for the Mayo Clinic to thoroughly review echocardiograms taken on all study participants. A formal peer review of the evaluation will be conducted in June 2001. Increased cancer rates have also been reported in Vieques, but the cancer registry is severely under-reported. After CDC upgrades the registry, ATSDR will assess the increased cancer rates.
At the Stauffer Chemical site in Tarpon Springs, Florida, the first report of the ATSDR Ombudsman was issued. The findings supported the science conducted by the Agency, but a review of additional data was recommended. With this new information, ATSDR was also asked to repeat the public health assessment (PHA) and implement further evaluation. At a recent town meeting, Dr. Falk assured the community that ATSDR did not interfere with the Ombudsman's autonomy in issuing an independent report. At a follow-up town meeting in June 2001, ATSDR will inform the community of actions that will be taken to respond to recommendations in the report.
Pediatric Environmental Health Specialty Units (PEHSUs). Units have now been established in each of the ten regions. Dr. Falk recently met with the March of Dimes and the Academy of Pediatrics to obtain additional support for continued development of PEHSUs. Providers at the units are treating patients, consulting with other pediatricians and conducting training programs in pediatric environmental health.
Issues for Consideration. Representatives from state health departments recently requested that a formal mechanism be developed for ongoing communication with ATSDR. The representatives proposed that a BSC subcommittee be established specifically for state health departments. Dr. Falk supports this concept, but ATSDR is seeking endorsement from the Board on this request. The BSC should also consider whether another mechanism would be more appropriate.
Since the Board's charter will expire in July 2001, consideration should be given to maintaining the name of "Board of Scientific Counselors," changing the name to "ATSDR Advisory Committee," or selecting another title that reflects a broader mission. The BSC is currently chartered to "provide advice and guidance on ATSDR programs; provide advice on the adequacy of science in ATSDR-supported research and research; and make recommendations regarding grants or specific research programs and conferences."
Dr. Falk noted that although the BSC does not peer review ATSDR's scientific projects, the BSC will provide guidance on program goals, objectives, strategies and priorities; provide advice on the direction, quality and scope of science, research and programs; and collaborate with constituents to fulfill ATSDR's mission. In addition to the state health department subcommittee, a possible name change and the current mission, the Board should also consider whether liaisons other than EPA and NIEHS should be added as members, i.e., NCEH and outside professional associations. Regardless of the BSC's decision, Dr. Falk emphasized that the CTS would remain intact.
Discussion. Dr. Melius requested that the members table their comments on the issues Dr. Falk asked the Board to consider. The current charter of the BSC and functions of other advisory bodies were distributed. The members were directed to review the materials for a detailed discussion on the following day. Since the $300,000 set-aside for the research agenda is extremely small, Dr. White suggested that ATSDR target prevention research initiatives as potential funding sources. Collaborating with NIH and other agencies that conduct prevention research for traditional public health chronic diseases may provide ATSDR with additional opportunities. She raised this point because environmental health is conspicuously absent from the field. Community-based research should be examined as well because these types of projects could provide a solid foundation for many of the Agency's existing activities.
Dr. Falk explained that the $300,000 set-aside was designated to list the funding as a line item for the research agenda. When ATSDR's operating plan is submitted, Congress will be able to identify APHER as a funded item. Ms. Stone requested additional details on ATSDR's site activities. In particular, she questioned whether the Agency enters communities based on actual needs or political ties at the site.
Dr. Falk conveyed that the needs of impacted residents are ATSDR's first priority. However, the HHS Secretary, Senators, Congressional members, the media or the public increase the focus at some sites. Communities that are not included on the National Priority List (NPL) petition ATSDR to take action. The majority of these efforts are undertaken by citizens who are concerned about health effects or environmental exposures at the site. Regardless of whether a petition is submitted by a high-level political official or community member, all requests are equally considered by ATSDR. Criteria have been established to evaluate potential health effects and exposures at a site. The Agency's policy is to complete an initial assessment and respond to petitions within 30 days.
Dr. Au invited Dr. Falk to present the proposed state health department subcommittee at a future CTS meeting in order to obtain additional input. The Special Consultants (SCs) have expressed concerns about state health departments not responding to communities and tribes or refusing to coordinate activities with ATSDR. Since health departments often serve as the first point of contact at the local level, Dr. Au underscored the need for ATSDR to obtain feedback from community and tribal representatives. Dr. Falk realized that performances of state health departments vary by location. With the establishment of the proposed subcommittee, he noted that the SCs would be able to ask questions or make comments directly to representatives of state health departments. He confirmed that he would welcome the opportunity to present this initiative at a future CTS meeting.
TopAlaska Traditional Diet Project. Dr. William Cibulas of the Division of Toxicology and Ms. Leslie Campbell of the Division of Health Assessment and Consultation (DHAC) presented one of ATSDR's newest initiatives. As the project develops, the Agency will emphasize native knowledge, information on environmental contaminants, as well as the risks and benefits of a subsistence diet for Alaskan Natives (ANs). The activity will be implemented by a multi-disciplinary team of 13 ATSDR scientists. The purpose of the initiative stems from a Congressional request for ATSDR to identify and study contaminants in the environment, subsistence resources and persons in AN populations. Congress earmarked $500,000 in FY'01 for ATSDR to fulfill this mandate and also directed the Agency to include all users of the subsistence or traditional diet in the project.
Congressional staff members reported that ATSDR was selected to conduct this activity because of its reputation in generating solid science, expertise in implementing community-based projects and strong ties to communities. The Agency also has a 15-year history of close collaborations with health care providers and governments at federal, tribal, state and local levels. ATSDR's extensive public health experience has been extremely valuable in assisting communities and tribal governments to identify and reduce exposures to environmental contaminants. Despite this expertise, however, the Agency still faced dilemmas in the Arctic. In particular, environmental contamination in Alaska has become an international issue because the cold acts as a sink for materials that migrate through the ocean and air currents.
Persistent organic pollutants, heavy metals and radionuclides from both local and distant sources are present in Alaska and serve as the top three categories of chemicals that are of most concern to residents. The increasing contamination is especially important to the 40%-90% of Alaskans who rely on traditional foods and a subsistence lifestyle. Although biomonitoring data show that the levels of contaminants in biological tissues are near or below background, ATSDR is aware of the public health implications associated with exposures to persistent toxic substances, such as reproductive, developmental and immunologic effects. In conducting activities, the Agency is also cognizant of diversities in geographic locations, ethnic and cultural lifestyles, and patterns of subsistence diets in Alaska.
In response to these issues, the multi-disciplinary project team first gathered information on dietary consumption patterns in Alaska, identified research needs, and obtained input from partners, native organizations and other stakeholders. The project team then developed a set of guiding principles to ensure that efforts would be culturally sensitive, community-based, inclusive and native-driven. Under this framework, ATSDR will also closely coordinate with relevant state agencies and ongoing Alaska projects; recognize regional and cultural differences; identify alternative funding sources and opportunities to leverage resources; and evaluate project activities, outcomes and impacts during each phase. Due to the small $500,000 earmark, ATSDR has been collaborating with CDC, EPA and NIEHS since these agencies are currently conducting relevant activities in Alaska.
In addition to the guiding principles, the team also created a mission statement and identified goals for the project. First, ATSDR will empower users of Alaskan traditional foods to make informed dietary decisions to prevent adverse health outcomes while incorporating traditional and western scientific information. Second, ATSDR will partner with other agencies to assist in identifying items in traditional diets and market foods consumed as well as to determine the health risks and benefits of traditional versus non-market diets. Third, ATSDR will develop a shared process of native knowledge and science to assure that appropriate levels of communication, education, training and community outreach are provided.
To achieve these goals, ATSDR collaborated with ANs to formulate a communication strategy that will include tribal consultation, input, alerts, notices and updates. ANs strongly recommended that the Agency examine the benefits as well as the risks of changing from a subsistence diet. In addition to federal agencies, the Governor's Office, Department of Health and Human Services, Department of Environmental Conservation, Fish and Game Agency, native organizations and other groups at the state level serve as key partners in the project. Agencies and tribes at federal, state and local levels are beginning to coordinate and collaborate to more fully develop the Alaska Contaminants Program. ATSDR is serving on an ad hoc workgroup that is leading this activity in an effort to integrate its Alaska project into the program. The Agency will use a portion of its funding to sponsor a workshop for ANs that will be held in the summer of 2001.
ATSDR is also collaborating with international partners to more effectively address environmental contaminants in Alaska, such as the Arctic Monitoring and Assessment Program. With FY'01 funds, the Agency developed a short-term project and presented the draft plan to partners. Based on feedback, ATSDR will identify traditional diets through an Alaska-specific dietary survey that is being created by nutritional experts in the state. Agency funding will be used to implement the survey, but the tool will be a local-level product. In the short-term, ATSDR will also begin to define exposure pathways to ANs and others who harvest traditional foods. ATSDR will make strong efforts to fund new partnerships with AN communities, health care providers and public health agencies. Linkages will also be established to support existing efforts related to potential environmental contamination of the food chain.
ATSDR will utilize funding to establish new partnerships with ANs. Through these efforts, two to four dietary surveys will be implemented in culturally and geographically diverse areas; standardized survey tools will be used; collaborative projects will be encouraged; and community-based capacity will be built. The majority of funds will be targeted to a health organization grant for ANs. Another existing activity ATSDR has been supporting is the EPA AN Science Commission Mini-Grants Program. Under this initiative, data will be collected to identify contaminants contained in harvested foods. Residents in local villages will be trained on gathering samples to be analyzed. ATSDR has also been collaborating with NIEHS to provide technical expertise to the agency's environmental justice (EJ) grant. Efforts will be made to ensure that data collected at the local level will be integrated with statewide data gathered through the dietary surveys.
Despite the fact that only one-year funding has been allocated to the Alaska project, ATSDR has still developed long-term strategies to address public health responsibilities. The Agency acknowledges the need to complete the dietary surveys in other regions, continue and expand contaminant sampling, and analyze nutrients and contaminants in both subsistence and store-bought foods. ATSDR realizes this public health response should continue with other activities as well, such as comparing subsistence and non-subsistence diets, developing and sharing information, seeking new and expanded collaborative efforts, and continuing tribal consultation. Even if additional funding is not allocated to the Alaska project, ATSDR hopes to continue its involvement by providing technical advice to the Alaska Contaminants Program.
During the next stage of the project, ATSDR will continue its communication strategy by providing updates and briefings to Congress and stakeholders throughout the year. Efforts will be made to strengthen partnerships, finalize the strategy and complete the project. Funds will be awarded in the summer of 2001 and most projects are expected to begin in the fall. Necessary training and capacity building will be initiated for villages to make informed dietary decisions as sovereign nations.
Discussion. Dr. Mangione inquired whether ATSDR will make suggestions to ANs on how to process food to ensure that additional contaminants will not be introduced. Ms. Campbell confirmed that the dietary surveys will include questions on preserving and preparing food. Dr. Roseman asked if ANs can reasonably expect that the goals and mission of the project can be achieved in the foreseeable future, particularly given the small funding amount. Dr. Cibulas replied that ATSDR has clearly stated the regional comparable dietary surveys will be initiated. The Agency has been forthcoming in conveying that no other activities can be completed with the small funding amount. He reiterated that ATSDR has underscored the need to continue the long-term strategies outlined for the project.
Ms. Campbell added that ATSDR will continue to closely collaborate with key partners and other stakeholders for the overall public health response. Due to the variability of individual diets in Alaska, Dr. Au agreed that ATSDR needs multi-year funding to achieve the project goals. He encouraged the Agency to formulate a stringent quality control component to collect and analyze data to ensure information can be effectively used and reproduced in the future. Ms. Campbell confirmed that under the Native American Research and Community Health Program, epidemiologists, nutritionists and other experts will develop solid quality control mechanisms to review the dietary data.
Ms. Stone questioned whether the Agency's findings have been presented to local communities, health departments or government officials. Ms. Campbell responded that ATSDR has been collaborating with grassroots organizations, individual community residents, tribal leaders and state representatives. She emphasized that funding for the project will be allocated at the community level. Because the data collection phase is currently underway, research results have not yet been obtained. However, she confirmed that the findings will be presented by local communities.
TopHealth Care Provider Education: Activities, Accomplishments and Strategies. Ms. Donna Orti of the Division of Health Education and Promotion (DHEP) provided the history of the Physician Education Program (PEP). The activity is based on language from the Superfund Reauthorization Act of 1986 that directed ATSDR to develop programs and materials for health care providers to inform, diagnose and treat persons who were concerned about environmental exposures. The Agency then co-funded the Institute of Medicine (IOM) to examine appropriate roles for primary care physicians in environmental and occupational health. The IOM concluded that the existing health care system was not adequately prepared to address problems related to occupational and environmental factors. This finding was based on the fact that of the 500,000 U.S. physicians in 1988, only 1,000 were Board certified in occupational medicine. However, 2,100 physicians are now Board certified in occupational medicine and an additional 5,000 physicians practice in this field.
To address this deficiency, IOM recommended that physicians follow five criteria to provide a minimum standard of care: (1) know the basic principles of environmental disease; (2) take an appropriate environmental history; (3) be sensitive to ethical, social and legal implications of an environmental illness diagnosis; (4) be alert to opportunities for prevention; and (5) call known or suspected hazards to the attention of public health agencies. To provide this minimum standard of care, IOM also recommended some interventions. Government agencies were encouraged to improve information sources for physicians; enhance availability of clinical consultation services; increase representation of environmental medicine in medical schools and primary care residency programs; and initiate environmental medicine research programs.
During the time of the IOM report, a survey was conducted among six communities to assess perceptions of chemical risk. The majority of respondents viewed physicians as the most trustworthy source, but residents were less likely to approach physicians to obtain this type of information. Based on these findings, ATSDR developed four strategies to address health care provider education. First, to increase the awareness of health professionals about environmental hazardous substances and related health effects, ATSDR provided information to physicians on behaviors that should be changed; developed skills among providers to maintain these changes; participated in national meetings of health care professionals; supported environmental health conferences; offered conference grants for organizations to present information and provide training on environmental exposures; and developed the Hazardous Substances & Public Health newsletter.
Second, to increase the ability of physicians and other health care professionals to obtain hazardous substances data, ATSDR funded a 1990 IOM report to examine the data needs of physicians; collaborated with the National Library of Science to develop a hazardous substances database; allocated funding to provide training; developed CD-ROM versions of its toxicological profiles; and coordinated with the 70 U.S. poison control centers to provide training to primary care providers on environmental issues. Third, to train and educate primary care practitioners to diagnose and treat illnesses caused by exposures to hazardous substances, ATSDR developed 33 case studies in environmental medicine in 1989. The documents are chemical-specific and allow primary care providers to earn continuing medical education (CME) credits.
Of the 33 case studies, eight have been published in journals for primary care providers. The documents were also disseminated to the memberships of several physician groups throughout the country. Moreover, the case studies are used in medical schools for undergraduate training in a variety of programs. Fourth, to support curriculum development and applied research in environmental health, ATSDR partnered with NIEHS and the National Institute of Occupational Safety and Health (NIOSH) to fund the EPOCH-Envi Program. This initiative educates physicians in occupational health and the environment through 46 two-day curriculum development workshops. Under this effort, 435 faculty members from 305 residency programs were trained in environmental medicine. Approximately two-thirds of these programs now include occupational environmental medicine in residency training.
ATSDR also funded a clinical fellowship program in environmental medicine. Of the 32 fellows who were supported to investigate environmental medicine research questions, 94% have generated data that were published. Despite developing the four strategies to strengthen health care provider education, ATSDR still asked IOM to make additional recommendations on the ideal environmental medicine curricula within medical schools. IOM's six competencies for medical school students were similar to those recommended for primary care physicians. In 1995, ATSDR funded IOM to develop an environmental medicine textbook. During this time, IOM also made recommendations for environmental medicine curricula for nurses. Under a national strategy, nursing school curricula were developed to specifically address environmental issues for communities in the Mississippi Delta Region. To date, 65 nursing faculty from five schools in the Delta Region have been trained in using in the curricula.
The Agency realized that PEP could not be established at the national level without solid partners. As a result, ATSDR created cooperative agreements to build capacity with state health departments and national organizations as well as collaborated with other federal agencies. To date, 37 state health departments and ten national organizations have been funded to partner with primary health care providers at state and local levels. Additionally, the national organizations conduct a variety of activities to expand training to a broader range of members, health professionals and other constituents. Because of these efforts, PEP is now a diverse and multi-faceted initiative. Through partnerships that have been established under PEP, awareness of over 200,000 U.S. providers has increased; 100 environmental health experts have been developed; 18,000 physicians have been trained in treating and diagnosing environmental illnesses; and a nationwide network of trained providers has been created.
PEP has also been designed for the continued growth of the environmental health field. This discipline is now included in several residency programs and medical school curricula. ATSDR's current strategic framework for PEP will continue to create an awareness of environmental health concerns; increase knowledge and improve skills of health providers to diagnose and treat illnesses related to environmental hazardous substances; develop and disseminate environmental health resources for health care professionals; and build capacity through partnerships with public agencies and health professional organizations.
Dr. Felicia Pharagood-Wade of DHEP conveyed that the PEP objectives are to increase the knowledge of primary care providers; improve the skills of primary care providers; and strengthen the capacity of the local health care system. To achieve these goals, DHEP created three programs. First, the Community Environmental Health Intervention Program was developed to improve local community access to environmental medical services. Under this site-specific activity, partnerships are established at the community level. The components of this initiative include an environmental medical needs assessment, clinical evaluation, a referral system and capacity building. To date, the program has been implemented at 14 sites and has directly impacted more than 5,500 community members. A medical referral network was established and physicians in local communities have been trained as well.
Second, the new Community Stress Program was developed to improve the skills of health providers, offer support to communities and providers, and address the fact that environmental factors increase stress levels. The components of this initiative include mental health services; professional stress education to local health providers and health officials at federal, state and local levels; and community support programs to provide education on mitigating stress levels and address relocation concerns. Under this program, the number of providers trained has increased 100%. In 2000, 103 providers were trained at five sites.
Third, the Provider Education Partnership Program was developed to improve the knowledge and skills of providers; promote partnership and collaboration; strengthen the capacity of the health system; and provide community support. The components of this initiative include three key activities. The National Organizations Partnership Project includes ten groups that promote multi-disciplinary collaboration and increase access to a broader range of providers. Outreach to project members has increased 400%. The PEHSU Project links the fields of pediatrics and environmental medicine. ATSDR, EPA and the Association of Occupational and Environmental Clinics (AOEC) collaborate in this effort.
Through ten PEHSUs, 30,641 consultation calls were made and training and education were provided to 8,805 providers in 2000. The Area Health Education Centers Project was developed to improve the skills of state health officials and health care providers in environmental health. Through four centers, support is provided to address the specific needs of populations that reside or work in U.S./Mexico border cities. To date, over 25 courses are offered in the curriculum and training is provided to more than 600 health providers and officials.
Ms. Janna Brooks of DHEP described some program tools that are used to implement PEP. Under Phase I of the environmental health care needs assessment, a health care system profile is developed to analyze the capacity and gaps in local health care resources, systems, services and referral networks. Existing data, community input, partners at state and local levels, and other resources are used in a holistic approach. The profile also defines target audiences and outlines the accessibility of health care services. Under Phase II, an educational needs assessment is developed to determine several areas among providers, including current level of awareness and practice in environmental health; topics of most interest; knowledge of site-specific health concerns; motivational tools that could be used; training preferences; and barriers to participating in the program.
DHEP also disseminates an environmental health card to ensure that physicians have a quick guide to evaluating environmental exposures. The pocket reference card serves as a clinical tool for primary care physicians to use in daily practice. The card increases the awareness and knowledge of fundamental environmental medicine concepts among providers and also improves the skills of physicians in identifying and evaluating potential environmental exposures. Since the card is currently in the development stage, DHEP is piloting mock products among national organizations and other partners to obtain feedback. ATSDR is requesting that the BSC provide input on the card as well. After the card has been enhanced and presented at meetings of national organizations, the Agency will aggressively market and distribute the product through medical groups.
Another tool that is being used to implement PEP is the community stress training manual. The document is designed to build capacity among professionals to appropriately address stress faced by residents at hazardous waste sites. In addition to ATSDR, staff members in other public health agencies at federal, state and local levels will be trained as well. ATSDR will also convene workshops for health care providers to ensure this population can recognize community stress caused by potential environmental exposures. The Agency has already been asked to provide assistance in this area to six EPA regional offices and five sites.
Dr. Ralph O'Connor of DHEP outlined the role of communication and evaluation in PEP. After ATSDR completes its update of the 33 environmental medicine case studies, CDC will re-accredit the tools for physicians, nurses and other providers. Although ethylene/ propylene glycol, gasoline, jet fuels and stoddard solvents are not commonly found at Superfund sites, case studies were developed since these chemicals are often detected at military bases. The case studies have been pilot tested to meet continuing education requirements. ATSDR sought input from a broad range of physicians, nurses and other health professionals in this effort. To better assist providers in diagnosing environmental illnesses, the updated case studies list medical conditions and potential chemicals that could cause these symptoms. In addition to the original 33 case studies, five new areas have now been added: children and environmental hazards, environmental asthma, immunologic disorders, iodine 131, and cancer clusters.
To further enhance PEP, ATSDR has planned or is considering a number of activities for the future: (1) place all case studies on the ATSDR web site; (2) offer online CME credits; (3) develop interactive case studies; (4) reassess the educational needs of health care providers; (5) focus more on health conditions rather than chemicals; (6) pilot multi-disciplinary projects to simultaneously train nurses and environmental health professionals; (7) develop educational tools as companions to the case studies; (8) use the BSC and other partners to aggressively market the case studies; (9) evaluate the effectiveness of different types of provider education; (10) design mechanisms to strengthen collaboration among ATSDR partners; (11) establish a one-month residency rotation program for physicians, nurses and other health professionals to enhance environmental medicine skills; and (12) increase the use of new technology through distance learning, satellite broadcasts, Internet, e-mail list servers and CD-ROMs.
In providing guidance about the future direction of PEP, DHEP asked the BSC to consider two questions: (1) Where should emphasis be placed in the strategic framework? (2) What additional modifications should be made in the future direction of the program?
Discussion. Dr. Melius was impressed with the activities and accomplishments of PEP, but he pointed out that the resources of the initiative are limited. If DHEP plans to use the Internet as both an information resource and educational tool to broadly reach health professionals, communities and other audiences, he noted that a substantial investment will be needed. He suggested that ATSDR take immediate steps to determine if additional funding for PEP will be through existing programs or other sources. Dr. O'Connor mentioned that as an initial step, all ATSDR programs have committed to placing information on the PEP web site.
Dr. Harris asked about the percentage of PEP providers who focus on underserved populations. Dr. O'Connor replied that these data have not yet been gathered because ATSDR would need to collect demographics on various communities and cross-reference the information with PEP service areas. Based on the list of sites at which ATSDR is currently involved, he speculated that the number of these types of providers would be high. In the Community Stress Program, Ms. Babich rged ATSDR to also emphasize additional stressful situations: when relocation is not an option and residents are forced to stay at a hazardous waste site; when impacted residents are not knowledgeable about potential adverse health effects or other outcomes; and when informed residents are placed in the position of developing skills to present data and share knowledge with other community members.
With respect to another PEP activity, Ms. Babich was frustrated with difficulties she has encountered in accessing the Los Angeles PEHSU. She asked ATSDR to provide guidance in overcoming this barrier. She also questioned whether the Agency has approached community leaders in the further development of PEP, particularly the community stress training manual. She offered to serve on a workgroup if ATSDR decides to obtain community input through this mechanism. Dr. Pharagood-Wade confirmed that she would convey Ms. Babich's suggestions about community stress to Dr. Pamela Tucker, the developer of the program. She also planned to inform Dr. Christine Rosheim, the PEHSU Project Officer, about the disconnect between the Los Angeles PEHSU and the community.
In terms of the community stress training manual, Dr. Pharagood-Wade remarked that the document has not yet been disseminated or used outside of ATSDR. However, she emphasized that the manual will indeed be circulated to partners and stakeholders for review and comment. Dr. Collins inquired whether physician assistants, obstetricians, nurse practitioners and managed care organizations are included in PEP activities. Ms. Orti replied that ATSDR makes strong efforts to reach community primary care providers at all levels, including those noted by Dr. Collins. The Agency also attempts to target specific provider groups at national meetings. ATSDR has already held discussions with managed care organizations in an effort to develop environmental health programs. Ms. Orti added that the Agency previously partnered with Kaiser Permanente at a federal facility site to provide education and convene grand rounds for the organization's physicians.
Dr. Roseman mentioned that many adults present to an optometrist, dentist or other specialist rather than a primary care provider. He asked if ATSDR is making efforts to educate these providers. He suggested that the Agency consider implementing demonstration projects with community health advisors. Dr. Pharagood-Wade responded that in addition to physicians, ATSDR also outreaches to allied health providers. For example, the environmental health card is specifically targeted to general and family practitioners, emergency medicine physicians and other providers who do not routinely treat patients with environmental exposures. However, she agreed that the providers listed by Dr. Roseman should be included as additional target audiences.
Ms. Gillick inquired about ATSDR's mechanisms to educate physicians who do not believe environmental problems exist in a community. She strongly encouraged ATSDR to enter sites earlier to address community stress issues and educate providers. She also recommended that emergency room nurses be included in PEP activities. Ms. Orti agreed stronger efforts must be made to change behaviors and increase awareness of environmental health issues among providers. For example, some children who have presented to physicians with methylparathione poisoning have been misdiagnosed with the flu because environmental exposures are not often seen in routine practice. Moreover, placing environmental health topics on grand round presentations is difficult due to competing issues. ATSDR will continue to encourage physicians to routinely take exposure histories; enter sites early to collaborate with community members; engage the local health care system; and implement health education activities.
In response to ATSDR's request for the BSC to provide guidance on PEP, Dr. Melius remarked that recommendations would be outlined on the following day. Dr. Roseman agreed to draft the Board's resolutions for PEP. Based on the discussion, outreach to providers other than primary care physicians, communities in need, and increased usage of the Internet were three key topics. Dr. Melius asked other BSC members to relay additional suggestions to Dr. Roseman.
TopPublic Comment Period. Ms. Judith Shoji revisited ATSDR's reasons for not expanding physician education initiatives. In terms of funding shortages, the Agency has not yet responded to her repeated requests for a complete breakdown of the budget by division and activity. As a result, she did not understand how lack of funding could be cited as an issue since the public has not been provided with these data. With respect to physicians' lack of interest in learning about toxins and Superfund sites, she did not agree with this statement. Indeed, physicians are willing to become more knowledgeable about environmental health if this opportunity is provided.
Ms. Shoji urged the BSC to read the Superfund mandate because the law clearly states that physicians and others should be educated. However, her position was that more resources and efforts should be placed in training physicians since patients most often present to doctors rather than other providers. Despite the PEP presentation, Ms. Shoji's information showed that physician education activities have decreased over time. For example, 81 grand round presentations or other types of meetings with doctors and nurses were held in 1991. Although the budget for physician education activities increased to $14 million in 1999, the meetings decreased to 24. Moreover, she has been informed that ATSDR will not make presentations to physicians at Emory University. She also learned that some AOEC members have ties with industry. Additionally, many physicians have no knowledge about ATSDR, Superfund sites or chemicals to which impacted residents are exposed.
Ms. Shoji hoped ATSDR would implement the activities proposed for PEP in the future. However, she suggested that less emphasis be placed on the community stress program. If medical problems of impacted residents are treated, stress will obviously decrease. Overall, she acknowledged that current efforts to train and educate physicians are insufficient. She was not aware of any patients consistently treated by doctors who were trained by ATSDR. In terms of national organizations, Ms. Shoji strongly emphasized that ATSDR is placing too much reliance on its partners. She informed the Board that more than 400 persons signed a petition in support of physicians and medical students being educated about toxins. She quoted a statement from the document that contained several requests. Persons interested in receiving the petition could contact Ms. Shoji at torakosh@yahoo.com. The document was submitted into the record and is attached to the minutes as Exhibit 1.1.*
Dr. Mamoru Shoji provided a medical perspective of the need to increase physician education and training. For example, some doctors may be unaware that the increase in diabetes over the last ten years is due to chemical exposures as well as diet. Additionally, some physicians may not fully understand the extremely complex issue of how chemical mixtures adversely affect the human body. To reach the broadest range of physicians and medical students, Dr. Shoji suggested that ATSDR compile environmental health data for publication in medical textbooks. He recommended that the "Frequently Asked Questions" section in the National Report of Human Exposure to Environmental Chemicals be widely disseminated because this information will be extremely helpful to physicians in diagnosing environmental exposures and measuring toxic levels. ATSDR should also provide data to regional centers so that all physicians can submit samples to these facilities, toxic chemical profiles can be developed, and detoxification programs can be established.
TopUpdate on ATSDR's Strategic Planning Process. Ms. Georgi Jones, of the Office of Policy and External Affairs, described developments that have occurred with this initiative since the last BSC meeting. To date, over 200 persons have been interviewed to determine ATSDR's strengths, weaknesses, opportunities and challenges. Respondents included ATSDR, CDC and EPA staff, state health departments, professional associations, national organizations and the CTS. Meetings were then held to discuss the Agency's vision, mission and goals. Respondents stated that the current vision, Healthy People in a Healthy Environment, was short, easy to remember, inspirational and consistent with ATSDR's authority. However, the language was not viewed as unique to the Agency and was believed to be too broad. The vision was also considered to lack direction and relevance for staff members. Agreement has now been reached on a new ATSDR vision: Protecting America's Health from Toxic Exposures.
Respondents stated that the current mission was action-oriented and consistent with ATSDR's authority, but was too lengthy and formal. The language was also viewed as misleading because the Agency does not "prevent exposure;" however, references to providing education were omitted. Agreement has now been reached on a new ATSDR mission: "To serve the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and diseases related to toxic substances."
The existing strategic plan states that ATSDR's goals are to "identify people at risk to exposure; evaluate the relationships between exposure and disease; and intervene to eliminate exposure or prevent disease." Respondents noted that the language was hard to understand, unclear and omitted references to communication and communities. As a result, the three current goals have been revised and expanded to five: (1) evaluate human health risks from toxic sites and releases and conduct timely responsive public health actions; (2) determine the relationship between exposure to toxic substances and disease; (3) develop and provide reliable and understandable information for affected communities and stakeholders; (4) build and enhance effective partnerships; and (5) foster quality work environment at ATSDR. The Agency is now in the process of developing strategic objectives for each goal. By June/July 2001, the final strategic plan should be completed and implementation will begin.
Discussion. Dr. Harris inquired about the time-line to disseminate the strategic plan for public comment. She pointed out that ATSDR's future efforts may be limited to domestic activities since the vision contains the word "America." Ms. Jones replied that the Agency's current mandate only focuses on domestic activities, but partnerships with Canada and Latin America can still benefit "America's health." However, if ATSDR's authority expands to an international program in the future, the language can be changed. In terms of the public comment period, Ms. Jones explained that the strategic plan is not scheduled to be finalized until October 2001. The document should be released for public comment after June/July 2001 and also placed on the Internet.
Dr. Collins mentioned that although human health risks will be "evaluated" under goal 1, the language does not describe specific actions to be taken by ATSDR. Dr. Melius agreed that preventive actions are not outlined in the goals. The language is more focused on process rather than outcomes and does not convey activities stakeholders expect ATSDR to conduct. He suggested that stronger action steps be included in the goals. Dr. Au mentioned that "toxic sites and releases" under goal 1 does not account for other situations in which exposures occur. For example, ATSDR's new project in Alaska cannot be not classified in either of these categories.
Ms. Jones explained that goal 1 is not limited to traditional sites because Brownfields or the mercury exposure in Midwestern homes would be included. Dr. Falk added that consideration is being given to including broader language of non-toxic "hazardous substances" in the strategic plan objectives. Dr. Roseman pointed out that no specific goal was developed for ATSDR to evaluate its activities and respond to feedback. Ms. Jones mentioned that this task will be outlined in the objectives.
Ms. Stone inquired if EJ was factored into the strategic plan since the EJ Executive Order requires each federal agency to include this language in its mission. Ms. Jones confirmed that as a key program in ATSDR, EJ will be reflected in the strategic objectives. ATSDR has already discussed designing some objectives to specifically address underserved populations in the areas of EJ and minority health. Dr. Sorber indicated that the goals preclude ATSDR's involvement in the field of biological warfare agents. In response to its request to be included in CDC's bioterrorism initiative, Dr. Falk reported that the Agency will receive $500,000 in FY'01 to develop medical management guidelines for toxic substances related to bioterrorism. ATSDR is also expected to receive approximately $2 million in FY'02 to collaborate with state health departments on identifying chemical agents potentially associated with bioterrorism.
TopNational Report on Human Exposure to Environmental Chemicals. Dr. Jim Pirkle of NCEH conveyed that since 1971, NCEH has participated in the National Health And Nutrition Examination Surveys (NHANES). During its involvement, NCEH has supported the inclusion of more toxic substance measurements in the questionnaire. NHANES is the only non-telephone survey conducted of the U.S. population; mobile trailers are used to collect data from each participant. Information is gathered through personal histories, 3,000-4,000 questions, and physical examinations, including blood and urine samples. NHANES data have been used to measure levels of lead, cadmium and cotinine. In the past, NHANES was conducted every eight or nine years for a four- to six-year period. Under a new design, however, NHANES will continuously sample the U.S. population each year. To obtain larger populations and more in-depth statistical analyses, samples for adjacent years can be combined.
The human exposure report was released on March 21, 2001 and was based on 1999 NHANES data. In addition to lead, cadmium and cotinine, 24 other toxic substances were added. The report will serve as an ongoing assessment of the general U.S. population's exposure to environmental chemicals. For purposes of the report, NCEH defined an environmental chemical as a "compound or element present in air, water, soil, dust, food or other environmental media." Metals, cotinine, organophosphate pesticides and phthalates were the four categories of environmental chemicals that were measured.
These important data will allow NCEH to identify the chemicals and levels that are entering the blood and urine of U.S. citizens; determine the prevalence of persons with elevated chemical levels to target interventions to at-risk groups; assess the effectiveness of public health efforts to reduce exposure; define reference ranges for unusually high chemical levels; track trends in exposure over time to make appropriate public health decisions; set priorities for human health effects research; and identify populations with high chemical levels, i.e., children, elderly persons and women of child-bearing age. The national report is an exposure document and does not contain new health effects data.
NCEH strongly emphasizes that chemicals which can be measured in blood and urine do not necessarily cause disease. Some chemical levels are too low to be of consequence to an individual's health. However, NCEH realizes that additional research is needed to more accurately interpret levels and determine the significance of these chemicals to human health. The outcomes of the report are as follow. No data were previously collected to which the 24 new chemicals can be compared. The data will provide invaluable information about population-based reference ranges in the form of geometric means, percentiles and demographic breakdowns by age, gender, race/ ethnicity and other standard variables.
New blood lead level data have been collected for children ages 1-5 years. The decrease in levels among the general U.S. population is particularly due to the ban on leaded gasoline and increased awareness of lead in dust as an exposure source. NCEH hopes to use the national report to illustrate that other chemicals in the U.S. population can also decline over time if exposure sources are removed. Another major finding related to exposure to environmental tobacco smoke. Data showed that serum cotinine levels among non-smokers dramatically decreased between the 1988-1991 and 1999 NHANES. The 75% decline was lower than detection limits and was due to efforts in the United States to reduce exposure to secondhand smoke.
For blood mercury levels, children were found to have 25% of the chemical as adults. With the submission of these data to EPA, NCEH hopes more accurate regulations for coal burning emissions can be set. For organophosphate pesticide metabolites, NCEH identified subpopulations that were at risk for these chemicals. As a result, aggregate effects of multiple pesticides will be analyzed. Phthalates are added to plastics, such as pacifiers, infant toys, vinyl products and cosmetics. Because of the wide use of these chemicals, NCEH first reviewed industrial production rates and EPA's toxic release inventory. The agency then initiated three studies to identify exposure pathways of phthalates into the human body. Preliminary data show that cosmetics and other products placed on the skin are major sources. Phthalates have been shown to cause birth defects in animals.
Platinum and beryllium levels in the 90th percentile were undetectable among the general U.S. population. Uranium-238 levels were present in the majority of NHANES participants. For persons with unusually high levels, NCEH is examining potential risk factors. In the next year of the national report, attempts will be made to add 25 more toxic substances to the current list of 27. This effort will be undertaken until the list of chemicals totals 100. These data will allow ATSDR and other agencies to make more informed decisions about chemical exposures among the general U.S. population. The information will also be used to develop better studies about the exposure/disease relationship and prioritize the most critical issues. In March 2002, NCEH will release an enormous amount of data on non-persistent pesticides, polyaromatic hydrocarbons, dioxins, furans, coplanar and non-coplanar PCBs. In January 2002, the agency will begin collecting data for volatile organic compounds. NCEH welcomes suggestions from ATSDR on adding additional compounds.
Discussion. Dr. McDiarmid noted that NCEH used only ten of the 90 NHANES geographic sites from which to measure uranium. She mentioned that this methodology is not appropriate for chemicals which are irregularly distributed. She suggested that NCEH use the samples which were collected to analyze data from additional sites. Dr. McDiarmid also remarked that the agency could compare its data with those collected by the National Geographic Survey from Department of Defense (DOD) facilities and other areas with high chemical levels. Dr. Pirkle confirmed that more sites were sampled with the 1999 NHANES data. NCEH selects 15 sites per year and a site-specific analysis will be conducted with the uranium data to identify unusually high levels.
Dr. Bennett inquired about NCEH's strategy to conduct longitudinal analyses and examine 100 samples at one time. Dr. Pirkle explained that if non-detectable levels are identified for more than three years, NCEH will most likely discontinue its analysis of the chemical for three years and resume the examination at a later date. With a rotation process, NCEH will be able to continually add new chemicals to the data set. If longitudinal studies are developed from NHANES, NCEH will follow the study population under a separate effort. However, Dr. Pirkle noted that NHANES is not the best mechanism to implement longitudinal studies. He added that resources could be better allocated if higher exposed populations are examined.
Dr. Roseman questioned whether arsenic will be added to the data set. He also asked if surveys had been conducted to determine knowledge among health care providers about chemical analyses in laboratories. To the first question, Dr. Pirkle replied that arsenic is currently included in the data set, but NCEH made the decision not to analyze the chemical until studies of particular species could be implemented. The agency expects to complete the arsenic study design in the next four months and begin collecting NHANES data in January 2002. To the second question, Dr. Pirkle responded that health care provider surveys have not been conducted. However, NCEH provides individuals with the names of acceptable laboratories upon request.
Ms. Stone inquired if NCEH tested soil at NPL sites where lead has been disposed of for a number of years. Dr. Pirkle reiterated that the national report is based on data from the general U.S. population rather than NPL sites or other point source exposures. NCEH does not conduct soil analysis unless an emergency occurs. Dr. Falk acknowledged that NCEH's data will continue to improve the quality of ATSDR's activities. In particular, the Agency will be in a better position to compare its site-specific findings with NCEH's national data. Dr. Grissom clarified that some chemicals have seasonal or regional variations. Depending on the location or time of year that measurements are taken, the possibility exists for data to be skewed.
Dr. Pirkle reported that NCEH will be releasing seasonal reference ranges within the next three months. The data will be categorized into four areas in the United States. The agency is also conducting studies of persons who use pesticides; measurements were taken before, during and after application. Dr. Au commented that NCEH's data will be more valuable to ATSDR if risk factors which contribute to an individual's outliers are known, such as occupational exposure. Dr. Pirkle mentioned that risk factor data are obtained from exposure questions on nutrition, physical health and other detailed demographic variables. However, NHANES is not the best mechanism to identify the contribution of an exposure source.
TopExposure Investigations (EI): Criteria for Collecting Biomarkers on Comparison Populations. Dr. Robert Johnson of DHAC defined an EI as an "approach for developing better characterizations of past, current and possible future human exposures to hazardous substances in the environment." In the continuum of relating environmental contamination with clinical disease, multiple steps occur. The contaminant is released into the environment, moves through media, causes exposure to humans, travels to tissues, has a biological effect and develops into clinical disease. During an EI, three types of data are gathered. Environmental samples are used to identify exposed populations. Biomarkers are examined to determine the degree of exposure. Exposure-dose reconstructions are conducted to model environmental contamination and identify past and future exposures.
EIs are not designed as research projects; instead, the activity is limited, small, site-specific and focused on highly exposed persons. To further enhance EIs, DHAC requested that the BSC consider the following question: Under what conditions would EIs be significantly improved by collecting comparison data from an unexposed group rather than relying on reference ranges? The pros and cons of both types of data are outlined as follows. For reference ranges, NHANES is considered to be the "gold standard" and currently contains a data set of 27 environmental chemicals. The data are well described, continuously updated and extremely useful.
Conversely, published data may become outdated as newer technologies are developed. Additionally, body burdens may change over time, while children, elderly persons and other special populations may not be included in the literature. Statistical descriptions of results may be limited as well. However, published data can be valuable because exposed populations are often tested and emphasis may be placed on occupational exposure levels. For comparison groups, published reference ranges are not needed; laboratory determinations are identical; sampling in exposed and non-exposed populations can be concurrently conducted; and populations with similar demographics can be selected. Conversely, both the cost and time to complete an EI will increase with comparison groups.
Despite these disadvantages, comparison populations are needed if no reference range exists, if the community has different characteristics from the general population, or if the subpopulation is the focus of the EI. Sample size, location of study participants, and social, economic, educational, dietary and cultural characteristics may all play a role in selecting a comparison population.
Discussion. Dr. McDiarmid described situations under which ATSDR should consider using comparison populations: when small excursions from normal are being examined; when outcome measures may be affected by multiple sources; when differences in gender exist; when background levels are variable, i.e., both environmental and occupational contributions; and special examples of endpoints, i.e., the need for concurrent populations with gene toxicology. Ms. Gillick inquired about ATSDR's criteria for selecting sites at which to use biomarkers. She recalled that when the Agency entered her site five years ago, the community was told testing would probably be conducted among impacted residents. To date, ATSDR has not undertaken this task. She encouraged the Agency to complete evaluations before making promises to the community. Ms. Gillick also urged ATSDR not to inform impacted residents that an exposure was not expected to be identified.
Dr. Johnson replied that site selection for an EI is based on four factors. First, the population at the site must be at high risk for exposure. Second, a data gap for which no other information currently exists for the exposed population must be present. Third, the EI must be able to fill the data gap. Fourth, ATSDR must be able to take public health action to address the exposure. To Ms. Gillick's comment, Dr. Johnson agreed that the Agency must make stronger efforts to honestly convey to communities expected outcomes at the beginning of site activities. Dr. Mangione mentioned that ATSDR should consider identifying control groups in concentric circles near an affected community rather than other locations. Dr. Melius agreed with this suggestion because ATSDR could quickly collect data from a nearby population, provide a more timely response to the community, and avoid the need for a comparison group. With this process, data collection and analysis could be simultaneously conducted.
Dr. Johnson confirmed that efforts are sometimes made to identify internal control groups to determine why some community members were not exposed. However, this approach is not often taken because a concentric circle assumes one point source instead of multiple pathways. Dr. John Abraham of DHAC added that ATSDR is increasing its use of Geographic Information Systems to identify exposure pathways. With this approach, a plume is defined and shows the area of potential exposure. Dr. Bennett conveyed that if small changes in the population are expected or high variability in laboratory results is likely, comparison data can be skewed. Dr. Spengler described three additional situations in which ATSDR should consider using comparison groups: if reference ranges were developed with old technology, if the information is outdated, or if reference comparison population data are not expected to be used for other groups. Dr. Falk announced that the possibility exists in the future for ATSDR to expand basic research by analyzing gene expression from exposure effects before clinical disease develops.
TopNew Developments in EJ and Health Disparities. Dr. Rueben Warren of the Office of Urban Affairs (OUA) explained that the office was established in 1997 to provide ATSDR with leadership in minority health, EJ and Brownfields. OUA's activities respond to the 1994 EJ Executive Order which states that each federal agency shall make EJ a part of its mission by identifying and addressing disproportionately high and adverse health or environmental effects of its programs, policies and activities on minority and low-income populations. OUA's initiatives also address research, education and health policy recommendations outlined in the 1999 National Academy of Sciences /IOM Report on EJ.
The report noted that a coordinated effort among federal, state and local public health was needed to improve the collection of environmental health data and to better link this information to specific populations and communities of concern. The report also stated that public health research related to EJ should improve the science base, involve affected populations and communicate findings to all stakeholders. The committee recommended that EJ serve as the focus of educational efforts to improve the understanding of these issues among community residents and health professionals. In instances where science was incomplete with respect to environmental health and EJ issues, the committee urged policymakers to exercise caution on behalf of affected communities, particularly those with the least access to medical, political or economic resources. Reasonable precautions were asked to be taken to minimize adverse health outcomes.
In addition to responding to these regulations and recommendations, ATSDR also addresses EJ concerns by serving on the EJ Federal Interagency Committee. In 1999, the committee developed an action agenda with the following goals: promote greater coordination and cooperation among federal agencies; make government agencies more accessible and responsive to communities; initiate EJ demonstration projects to develop integrated place-based models for assessing community livability issues; and ensure the integration of EJ in policies, programs and activities of federal agencies. In May 2000, the committee designated 15 demonstration projects throughout the United States.
The Minority Health and Health Disparities Research and Education Act of 2000 serves as another mechanism in which ATSDR is involved in EJ issues. The purpose of this legislation is to improve minority health, reduce health disparities, conduct health disparities research, collect data related to race/ethnicity, educate health professionals, increase public awareness about health disparities and disseminate information. Strong efforts are currently being made by multiple stakeholders to add environmental science and health to the legislation.
For internal EJ activities, ATSDR is currently involved in the Mossville, Louisiana site to improve access to primary care. In 1998, the Agency entered into a Memorandum of Understanding with the Bureau of Primary Health Care (BPHC) to increase and enhance environmental medicine in all centers. In 2000, ATSDR provided an update on dioxin to local health providers. Also in that year, a CME course on environmental health was provided to 50 nurses from the local health department and community health center at the Memphis, Tennessee site. Based on an evaluation, the course was well received by participants. A similar course for physicians is currently being developed. BPHC has asked that this module be offered to all of its primary care associations.
The Defense Logistics Agency has made a written commitment to facilitate access to primary care for the Memphis Depot community and assist residents in determining how the 625-acre site will be used. In Corpus Christi, Texas, ATSDR is collaborating with EPA and local agencies to improve relationships with Hispanic residents, address community concerns and strengthen data analysis for several municipal landfills. In Columbia, Mississippi, ATSDR continues to collect data and conduct other site activities because the community was not confident that problems were resolved after the PHA was completed. The Agency and community agreed to separate the Superfund and Brownfields issues to improve access to primary care among impacted residents. Although ATSDR will provide support to all of these site-specific efforts, the activities are being developed by partners and will be sustained at the local level.
For minority health initiatives, ATSDR has developed partnerships with African American and Hispanic professional medical associations. In particular, the Agency supported two symposia on EJ and environmental health among women and children. The task force that resulted from this effort is committed to enhancing the knowledge and skills of National Medical Association members. ATSDR has and continues to provide support to Historically Black Colleges and Universities. Under these cooperative agreements, funded institutions are encouraged to develop environmental health curricula. In collaboration with CDC, EPA and NIH, ATSDR is funding community research on environmental health in the Mississippi Delta Region. Demonstration projects are currently underway in Memphis, Tennessee; Jackson, Mississippi; New Orleans, Louisiana; and Little Rock, Arkansas. For each activity, a community-based organization serves as the principal investigator. This initiative has great potential to make a positive impact on minority health.
ATSDR has also strengthened efforts to increase programmatic activities with Hispanics and Native Americans. In September 2001, ATSDR will participate in a national summit to eliminate racial and ethnic health disparities hosted by HHS. The Agency submitted the names of more than 100 community-based organizations to attend the conference as well. The goal of the summit will be to identify lessons learned and compare these outcomes with the Healthy People 2010 objectives. ATSDR will continue to collaborate with CDC, other federal agencies and non-governmental organizations to address minority health issues.
Discussion. Ms. Stone was pleased with ATSDR's accomplishments in the areas of EJ and minority health, but she pointed out the need to expand these activities to other sites. She was concerned about the lengthy delay in implementing these types of programs and disseminating information on a broader scale. For example, some communities in need have been waiting for up to ten years to receive these services. Dr. Warren explained that the initiatives he described have not yet been evaluated. As a result, full-scale implementation cannot occur at this time. He also mentioned that EJ and minority health activities must be conducted with strong community leaders, committed stakeholders and authority at the local level. He made a commitment to partner with Ms. Stone to begin developing an EJ/minority health program at her site.
TopPublic Comment Period. Ms. Babich noticed that the public comment period was limited to agenda items. Her position was that citizens should feel free to raise any issues before the Board. Dr. Falk assured Ms. Babich that the public is not restricted to making comments on agenda items. He added that this language will be deleted from future agendas.
Mr. Marvin Crafter, of the Woolfolk Citizens Response Group in Fort Valley, Georgia, submitted into the record the final report of the "Community Environmental Health Intervention Program." The document is attached to the minutes as Exhibit 2.2.* The report emphasizes the need for communities to receive additional environmental health care services. During the data collection process, surveys were conducted to determine the number of impacted residents who had insurance. Despite the fact that contamination in the Fort Valley community has reached epidemic proportions, the findings showed the majority of environmentally exposed community members are poor and have no resources to pay for needed health care services.
If vaccinations and other medical services are provided free of charge to control smallpox, polio and other diseases, Mr. Crafter did not understand why similar actions could not be taken to address environmental illnesses. He was also unsure of the need for the government to continue to collect data on contaminants that are already known to cause adverse health effects or death. He urged ATSDR to more closely focus on the "disease registry" component of its mission and CDC to more strongly emphasize its mandate to "control" diseases.
Ms. Doris Bradshaw of the Memphis Depot community in Tennessee made two observations about meeting process. First, the Federal Advisory Committee Act states that meeting minutes should be detailed and presenters' names should appear with their comments. However, minutes for CTS meetings are not specific enough for readers to understand the group's activities because speakers are not identified. Second, ATSDR is reluctant to take the opinions and advice of community members into consideration. For example, Ms. Bradshaw submitted Mr. Dan Fahey's paper on depleted uranium exposures into the record of the CTS meeting. However, she was informed that ATSDR would not accept the document until a BSC member named in the paper had an opportunity to respond to the comments. Ms. Bradshaw's understanding was that regardless of their opinion or position, community members could submit documents into the record of a federal public meeting. She submitted Mr. Fahey's paper into the record of the BSC meeting. The document is attached to the minutes as Exhibit 3*. She asked the Board to address the two issues she raised.
Ms. Stone noted that many domestic and international communities have not acquired a support base. To emphasize this point, she distributed several photographs of impacted sites. For example, military ranges are located in the heavily populated community of Seaside, California. The site contains explosives, barb wire fences and "keep out" signs. If strong efforts are made in the United States to correct these problems, Ms. Stone believed that the successes could be replicated in Africa, India and other countries with neglected citizens in the future.
There being no further discussion, Dr. Melius recessed the BSC meeting at 4:57 p.m. on May 3, 2001.
Top_________________________________________________________________________________________________________
Unfinished BSC Business. Dr. Melius reconvened the BSC meeting at 8:34 a.m. on May 4, 2001 and returned to some outstanding agenda items. He pointed out that a document was distributed which proposed a new title, function and structure changes for the BSC. Dr. Melius was not in favor of changing the Board's name, but he agreed that the function could be revised to be consistent with other federal advisory committees. Dr. Bennett noticed that the proposed function places a stronger emphasis on science than the existing charter. He mentioned that this new responsibility would be consistent with ATSDR's plan to implement an extramural grants program.
Dr. Falk did not support a peer review function being added to the Board's charge. His position was that the BSC's responsibility for broad oversight of ATSDR's research agenda and scientific programs should be maintained. However, he was in favor or changing the charter to acknowledge that the Board is used for other advisory issues, such as the strategic plan and shared vision with NCEH. Dr. Sorber agreed that the name should not be changed, but he endorsed the proposed function of the BSC providing advice on ATSDR's programmatic goals, objectives, strategies and priorities.
Dr. Mangione remarked that the title "advisor" is used more often in professional settings than "counselor." She also supported the proposed function because the existing charter is extremely specific and includes many tasks the Board does not undertake. Dr. Harris voted to adopt the proposed function and structure changes as well. Dr. Bowler remarked that because the members represent multiple disciplines, the BSC should be more actively involved in advising ATSDR on its extramural research program in addition to providing guidance on strategies and policies. Dr. Falk clarified his earlier statement. Although all of ATSDR's research activities will not be presented to the Board for peer review or assessment, the members could indeed play a more active role in certain research projects. He asked the BSC to convey areas of interest to Dr. Spengler.
Dr. Melius returned to the suggestion to establish a state/local health department subcommittee. He endorsed the concept because the group could serve as a solid mechanism for ATSDR to obtain additional input. Dr. Au was also in favor of the new subcommittee, but he strongly emphasized the need for close interaction with the CTS. Ms. Gillick supported the new subcommittee because ATSDR provides funding for states to conduct site activities. Since health departments at state and local levels often serve as the lead agency at impacted communities, the new subcommittee could provide a forum for concerned citizens to describe local problems. She also noted that the group could enhance collaboration and coordination with ATSDR and other federal agencies.
Dr. Mangione encouraged ATSDR to designate representatives from CSTE and other outside organizations to serve on the state/local subcommittee in an ex officio capacity. Dr. Bennett reported that EPA acknowledges federally recognized tribes in the same manner as states. He inquired whether ATSDR has given consideration to including a representative from a federally recognized tribe on the state/local subcommittee. He mentioned that CSTE, ASTHO, NACCHO and other organizations which represent groups of states are not co-implementers of activities under the Superfund law. Dr. Bennett was not certain that these types of groups can serve on federal advisory committees.
Dr. Falk clarified that representatives from state health departments with ATSDR cooperative agreements would serve on the new subcommittee, but not on the BSC. However, a Board member would be expected to chair the group. Similar to the CTS, the new subcommittee would not be chartered as a federal advisory committee. Dr. Falk followed up Dr. Mangione's comment and asked the BSC to suggest additional liaisons who could serve on the new subcommittee, such as NCEH or non-governmental organizations. Dr. White noted that in addition to NCEH, other CDC divisions could also serve as liaisons to more closely focus on community needs. She recommended that consideration be given to including representatives of chronic diseases and other health effects CDC addresses. This involvement will strengthen the integration of environmental health into CDC's existing programs.
Dr. Roseman responded to Dr. Melius' charge by listing the Board's recommendations to ATSDR about PEP. These items are outlined in "New BSC Business." Many Board members agreed that the field of environmental health is one of the most significant gaps in medical school curricula and routine practice of physicians. In response to this observation, Dr. Falk was pleased to announce that some first-year medical students at Emory University will soon be visiting ATSDR. The seminar will allow the Agency to provide students with an overview of environmental health and other site activities. He hoped ATSDR could conduct similar events in the future.
In addition to the providers previously suggested for inclusion in PEP activities, Dr. Collins mentioned that ATSDR should make an effort to target developers of medical board examinations as well. Dr. Falk reported that the Agency has already taken steps in this area. The Office of Children's Health has met with the American Board of Pediatrics to ensure that pediatric environmental health questions are included in medical examinations. However, he acknowledged that other populations are not being addressed in this regard. Dr. Bowler noted that neuropsychologists should be considered as another target audience for PEP. Since many physicians in this field have limited knowledge of ATSDR and environmental health, she recommended that the Agency make presentations at annual meetings of psychology associations.
TopReport of the CTS Meeting. Dr. Au, the CTS Chair, announced that since the last BSC meeting, the CTS membership has changed. Dr. Sorber now serves as a BSC representative; Ms. Linda Gillick and Ms. Vivian Jones are new SCs. The CTS is also in the process of selecting two new SCs to represent tribes. Both ATSDR and Dr. Au have made presentations to the CTS on community health assessment studies, but Dr. Au pointed out that his site activities are not funded by the Agency. The purpose of these presentations was to illustrate to the CTS and SCs how certain factors can affect ATSDR's PHA process, such as current and previous exposure to mixtures; modifying factors among different persons; the ability of different agents to cause the same disease; communication barriers among communities, scientists and agencies; and coordination problems with multiple agencies.
Dr. Au reminded the Board that the concept of the CTS task forces was presented at the last BSC meeting. The mechanism was developed to enhance the productivity of the CTS. For example, the task forces can make specific recommendations to ATSDR on factors that affect the PHA process in the future. The three topics currently being addressed by the task forces are how to improve cultural sensitivity training of ATSDR staff; how to involve and engage communities with disparate groups; and how to communicate toxicology and public health information. The first session of the task forces was convened during the November 2000 CTS meeting, but the second session that was scheduled for the May 2001 meeting was not held. Some SCs requested that the time be devoted to a discussion on improving the overall CTS meeting process. As a result, Dr. Au was unable to provide the second report of the task forces, but he expected to describe the progress of the groups during the next BSC meeting.
The recommendations, agenda items and action items raised during the May 2001 CTS meeting are outlined below.
Discussion. Dr. White suggested that ATSDR release documents for public comment on its web site. Dr. Spengler explained that resources and technical expertise must be taken into consideration with this approach. However, he explained that the Agency will explore all feasible options to respond to this recommendation. Dr. Collins emphasized the importance of the recommendation for ATSDR to develop more user-friendly mechanisms for communities to seek assistance. She indicated that perhaps the Agency could provide guidance to the SCs on this issue.
Mr. Larry Cseh of DHAC explained that PHS has established the Commission Corps Readiness and Crisis Response Unit. Under this mechanism, a cadre of officers from different federal agencies are deployed to emergency response units. Additionally, national units are trained to address bioterrorism, emergency spills and other crises. Since the CTS will clarify its recommendation on relocation policies and mobile emergency response units, Dr. Spengler suggested that Mr. Cseh present this information at a future CTS meeting. Dr. Melius entertained a motion to approve the CTS report for formal submission to ATSDR. Dr. White so moved; Dr. Collins seconded the motion. There being no further discussion, the report of the May 1-2, 2001 CTS meeting was unanimously approved.
TopATSDR/NCEH Shared Vision for Environmental Public Health. Dr. Falk conveyed that collaboration between the two agencies is inevitable since Superfund programs were previously implemented by CDC. Although the relationship between ATSDR and CDC has historically been solid, collaborative efforts could be stronger. As a result, Dr. Falk's goal is to enhance the functional relationship and coordination between the two agencies. The issue of whether to merge ATSDR and NCEH has recently been revisited by the Pew Commission. The group's position is that the merger would improve disease tracking, but whether actions will be taken to address this recommendation is an uncertainty at this point.
At the directive of Dr. Jeffrey Koplan, the ATSDR Administrator/CDC Director, the two agencies met in 2000 to begin a dialogue on developing a shared vision. The overall purpose of this activity is to eliminate confusion, avoid overlap and enhance the missions of both agencies. On the one hand, NCEH's public health advisors and laboratorians are extremely beneficial to ATSDR. The Agency has made extensive use of NCEH's human sample measurements, biomonitoring data and environmental health card. On the other hand, ATSDR's risk assessors, health educators, environmental scientists, engineers, hydrologists, geologists, public health assessors, and evaluators of EPA regulatory materials make a significant contribution to NCEH's initiatives. Despite the differences between the two agencies, Dr. Falk saw enormous opportunities to complement activities.
Ms. Jones explained that during the next phase of the shared vision, ATSDR and NCEH will continue internal and interagency communication; initiate discussion and feedback from the BSC, NCEH Advisory Committee and other external partners; inventory current expertise in both agencies; identify additional resources needed by both agencies; and establish joint workgroups for asthma, toxicology, the Alaska Native project, and cooperative agreements.
Discussion. Dr. Harris questioned whether NCEH has developed an EJ/minority health initiative. Dr. Falk replied that an EJ/minority health coordinator addresses these issues in NCEH, but the activity is focused at the national level. NCEH's program is not as extensive or site-specific as ATSDR's EJ/minority health initiative. In addition to the four shared vision workgroups that will be established, Ms. Stone asked if ATSDR could convene separate focus groups to address other issues at Superfund sites and federal facilities. Dr. Falk reported that ATSDR, NCEH and NIOSH have formed a coordinating group to jointly plan efforts and implement activities at federal facilities. This initiative has been underway for the past three years.
TopUpdate on Pew Commission Activities and ATSDR's Involvement. Dr. Falk reported that Pew developed two reports to address the country's need for a national health tracking network and the need for a stronger public health defense against environmental threats. The national health tracking report outlined five tiers: a national baseline tracking system of chronic, environmental and infectious diseases and exposures; a national early warning system; state pilot tracking programs; a public health investigative response; and tracking links to communities and research. To address these areas, Pew recommended that Dr. Koplan submit a nationwide health tracking network plan to Congress in 2001. Dr. Koplan established an ATSDR/CDC committee to respond to the report.
The committee was divided into three groups to more closely focus on the three key areas outlined in the report and make appropriate suggestions. For surveillance, existing disease tracking systems for cancer, birth defects and asthma will need to be expanded and enhanced since these registries were not uniformly established throughout the country. New disease tracking systems will need to be developed for neurological and immunological diseases as well as learning and developmental disabilities. Experimental data suggest that chemical exposure may play a role in these conditions. Environmental and occupational exposure tracking systems will need to be strengthened to obtain better data on lead poisoning, pesticide poisoning and waterborne diseases. Information from the Hazardous Substances Emergency Event Surveillance System and poison control centers need to be improved as well.
For biomonitoring, NHANES will need to be expanded to selected states and replicated on a smaller scale for community investigations. Environmental data from different agencies will need to be integrated into existing databases. New community indicator databases will also need to be developed. For infrastructure, capacity among state-based personnel will need to be strengthened and a federal response team to support states will need to be established. If actions in these three areas are taken, the ATSDR/CDC response committee pointed out that studies which link diseases, exposures and environmental data could better determine association.
On May 3, 2001, Dr. Koplan gave a preliminary response to Pew's recommendations in a Congressional appropriations hearing. In terms of ATSDR's role in responding to the report, the President's budget request for the Agency that was proposed to Congress has a $2.5 million increase. If appropriated, the funding will be used to develop a national environmental disease surveillance system with an emphasis on Superfund sites. Because of Pew's strong efforts to engage Congress in its interests, Dr. Falk was certain that legislation will be proposed in 2001. He also expected that an extensive planning effort will be initiated to narrow down the recommendations and identify a starting point. Dr. Koplan will most likely request that ATSDR and CDC design a mechanism to obtain broad input and collect data from other federal agencies and external organizations.
Discussion. Dr. White was pleased with ATSDR's involvement in responding to the Pew report because the surveillance data will play a significant role in both retrospective and prospective studies. Dr. Roseman asked why endocrine disorders were not suggested for a new disease tracking system. Dr. Wendy Kaye of the Division of Health Studies replied that existing chronic disease surveillance systems already include diabetes and cardiovascular disease. The group attempted to focus on new diseases, but new conditions can be added in the future and linked to environmental data. She also raised the possibility of conducting pilot projects for these disorders.
Dr. Falk confirmed that the four new disease tracking systems recommended by the ATSDR/CDC response committee is an initial effort. He indicated that if interest increases for Pew's activities, external workshops and conferences may provide opportunities to add additional diseases. He mentioned that establishing a national registry will require extensive discussion and endorsement from a variety of stakeholders. Dr. Au questioned whether the expanded NHANES will focus on factors other than diet and age, such as job and health histories. Dr. Falk responded that this component is a possibility, but the burden of participating in NHANES must be taken into consideration. The physical examination is completed in four hours, while the questionnaire takes additional time. He raised the possibility of selected NHANES or community-HANES participants completing an expanded questionnaire.
TopPublic Comment Period. Dr. Melius opened the floor for public comments; no attendees responded.
TopNew BSC Business. The action items, agenda items and recommendations raised during the meeting were reviewed by the BSC and are outlined below.
Action Items/Recommendations
Agenda Items for the BSC Meeting
Agenda Items for the Joint BSC/NCEH Advisory Committee Meeting
Closing Session. The next Board meeting will be held on November 15-16, 2001 at the Sheraton Inn-Colony Square in Atlanta. On the first day, the BSC and NCEH Advisory Committee will meet separately during the morning session and then hold a joint meeting in the afternoon. The following BSC meeting is tentatively scheduled for May 2-3, 2002.
There being no further discussion, Dr. Melius adjourned the BSC meeting at 11:28 a.m. on May 4, 2001.
____________________________________________________________________________________________________
I hereby certify that to the best of my knowledge, the foregoing Minutes of the proceedings are accurate and complete.
Dr. James Melius, Chair----------------------------------------
*Due to length of document, ATSDR will provide this exhibit upon request.
Top This page last updated on January 12, 2002
Information Center / atsdric@cdc.gov
ATSDR Home |
Search |
Index |
Glossary |
Contact Us
About
ATSDR | News Archive |
ToxFAQs | HazDat
| Public Health Assessments
Privacy Policy |
External Links Disclaimer |
Accessibility
U.S. Department of Health and Human Services