Children's Health Protection Advisory Committee
Chair:
Sheela Sathyanarayana, MD, MPH
University of Washington
Department of Pediatrics
Seattle Children's Research Institute
2001 8th Avenue
Seattle, WA 98101
(206) 884-1037
Sheela.sathvanaravana
@seattlechildren's.orq
Committee Members:
Ellen Braff-Guajardo
Patrick Breysse, PhD, CIH
Tyra Bryant-Stephens, MD
Susan Buchanan, MD, MPH
Stephanie Chalupka, EdD, RN, PHCNS-
BC, FAAOHN, FNAP
Nancy Clark, MA, CIH, CSP
Jennifer Counts, PhD
Joel Forman, MD
Maeve Howett, PhD, APRN, CPNP-PC,
IBCLC
Gredia Huerta-Montanez, MD
Lloyd Kolbe, PhD, MS
Sandra W. Kuntz, PhD, APRN, CNS
Lawrence Lash, PhD
Jeanne Leffers, PhD, RN
Jennifer Lowry, MD
Leyla McCurdy, MPhil
Barbara Morrissey, MS
Thomas Neltner, JD, CHMM
Greg Ornella, MD, MS
Joanne Perron, MD, MPH
Brenda Reyes, MD, MPH
Kate Sande, MS
Martha S. Sandy, PhD, MPH
Adam Spanier, MD, PhD, MPH
December 23, 2014
Administrator Gina McCarthy
United States Environmental Protection Agency
1200 Pennsylvania Ave, NW
Washington, DC 20460
RE: CHPAC Fish Advisory Recommendations
Dear Administrator McCarthy:
Thank you for the opportunity to comment on the Draft Updated Advice
by FDA and EPA: "Fish: What Pregnant Women and Parents Should
Know." CHPAC supports the continued update offish advisories
including the added emphasis on the health benefits of fish
consumption in advisory messaging.
CHPAC commends EPA on its recent efforts to achieve long-term
reductions in mercury loading to U.S. waterways through the Mercury
and Air Toxics Standards, proposed effluent limitation guidelines and
standards for steam electric power plants, and by supporting the U.S.
government in signing the Minamata Convention on Mercury.1"3 We
hope these pollution source reduction efforts will translate into lower
methylmercury concentrations in fish.
Fish are a nutrient rich and culturally important food but are also the
primary source of methylmercury exposure in the U.S. population.4,5
Notably, EPA recently estimated that 2.14% of U.S. women of child-
bearing age have blood levels of methylmercury above the EPA
reference dose (5.8 |jg/L).5Thus, more than one million women of child-
bearing age in the U.S. exceed the EPA level,6 potentially placing their
unborn children at risk of adverse neurodevelopmental effects.
1 U.S. EPA. "EPA Mercury and Air Toxics Standard". 2012. http://www.epa.gov/mats/index.html.
2 U.S. EPA. "Draft Regulation: Effluent Limitations Guidelines and Standards for Steam Electric Power Generating Point Source
Category". 2009. EPA-HO-OW-2009-0819. http://vosemite.epa.gOv/opei/rulegate.nsf/bvRIN/2040-AF14#l.
3 U.S. EPA. "Minamata Convention on Mercury". 2013. http://www2.epa.gov/international-cooperation/minamata-convention-
mercury.
4 National Research Council. "Toxicological Effects of Methylmercury". 2000. National Academies Press.
http://www.nap.edu/catalog/9899/toxicological-effects-of-methvlmercurv.
5 U.S. EPA. "Trends in Blood Mercury Concentrations and Fish Consumption among U.S. Women of Childbearing Age. Final
Report." July 2013. NHANES, 1999-2010. EPA-823-R-13-002.
6 U.S. Census Bureau. "American Community Survey. 2013 Estimate of U.S. Women Aged 15-44: Table of Age and Sex
(S0101) 3-year estimate". 2013.
http://factfinder2.census.gov/faces/tableservices/isf/pages/productview.xhtml?pid=ACS 13 3YR SOlOl&prodType
=table.
Children's Health Protection Advisory Committee is a Federal Advisory Committee for the
U.S. Environmental Protection Agency under the Federal Advisory Committee Act
http: //yosemite.epa. gov/ochp/ochpweb ,nsf7content/whatwe advisorv.htm
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Administrator McCarthy
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Moreover, the burden of methylmercury exposure is likely to be greater among high fish-
consuming sub-groups.7
CHPAC offers the following recommendations and comments on the combined FDA and EPA
draft advice.
Charge 1: Should orange roughy and marlin be added to the "do not eat" list for pregnant
women, breastfeeding women, and young children?
CHPAC reviewed the available published data on orange roughy and marlin8"17 and the updated
FDA dataset on mercury content in fish which showed that 63% of orange roughy samples
(surveyed 2002-2009) and 44% percent of the marlin samples (surveyed 1992-96) contained
more than 0.50 ppm mercury.18 As a result of this broader data review, CHPAC recommends
that EPA:
a) Include both orange roughy and marlin in the advisory in the "do not eat" group because
of their high mercury and low omega-3 fatty acids content.
Further, CHPAC is concerned that consumers will assume that other fish species high in
mercury, but not specifically named in the advisory, are safe for pregnant women to eat 2-3
times per week. Some of these fish, such as grouper and fresh and frozen tuna, have higher
7 Karimia R, Silbernagel S, Fishera N. S, Melikerba J R. "Elevated blood Hg at Recommended Seafood
Consumption Rates in Adult Seafood Consumers". 2014. International J. Hygiene Environ. Health. 217:758-764.
8 Health Canada, Bureau of Chemical Safety. "Human Health Risk Assessment of Mercury in Fish and Health
Benefits of Fish Consumption: Appendix II: Summary data for those fish species for which samples contained total
mercury at levels greater than 0.2 ppm on average". 2007. ISBN: 978-0-662-47023-6. http://www.hc-sc.gc.ca/fn-
an/pubs/mercur/merc fish poisson-eng.php#appb.
9 Unninayar CS, Ito BM. "Status Report: Mercury in the Pacific Blue MarlinMakaira nigricans". 1975. NOAA,
National Marine Fisheries Service: Southwest Fisheries Center. Administrative Report No 2H.
10 Shomura RS, Williams F. "Proceedings of the International Billfish Symposium, Kailua-Kona, Hawaii, 9-12
August 1972. Part 2. Review and contributed papers". NOAA ccTechnicalReport. 1974. NMFS SSRF-675.
11 Shultz CD, Crear D. "The distribution of total and organic mercury in seven tissues of the Pacific blue marlin,
Makaira nigricans".1916. Pacific Science. Vol. 30 (2): 101-107.
Cai Y, et al. "Bioaccumulation of mercury in pelagic fishes from the northern Gulf of Mexico". 2007. Can, J.
Fish Aquat. Sci. 64: 458-469.
13 Dabeka RW, et al. "Levels of total mercury in predatory fish sold in Canada in 2005". 2005. Food Additives and
Contaminants. 28 (6): 740-743.
14 Hightower JM, Brown DL. "Mercury concentrations in fishjerky snack food: marlin, ahi, and salmon". 2011.
Environ. Health 10:90-94. http://www.ehiournal.net/content/10/1 /90.
15 Van den Broek WLF, Tracey D M. "Concentration and distribution of mercury in flesh of orange roughy
(Hoplostethus atlanticus)". 1981. New Zealand Journal of Marine and Freshwater Research. 15(3):255-260.
16 Julshamn K, Mage A, Tyssebotn 1MB, S;ethrc LJ. "Concentrations of mercury and other toxic elements in orange
roughy, Hoplostethus atlanticus, from the Mid-Atlantic Ridge". 2011. Bulletin of Environmental Contamination and
Toxicology. 87(l):70-3.
17 Cronin M, Davies IM, Newton A, Pirie JM, Topping G, Swan S. "Trace metal concentrations in deep sea fish
from the North Atlantic". 1998. Marine Environmental Research. 45 (3): 225-238.
18 U.S. FDA. "Mercury Concentrations in Fish: FDA Monitoring Program (1990-2010)". 2014.
http://www.fda.gov/Food/FoodborneIllnessContaminants/Metals/ucml91007.htm.
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Administrator McCarthy
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mercury levels than albacore tuna which the advisory specifically19 limits to one serving a week
(6 oz). To improve the clarity of the guidance, CHPAC recommends that EPA:
b) Consider adopting a tiered consumption guide (e.g., green, yellow, and red lights) such
as those used by many states. This would allow EPA to provide specific guidance for a
broader number of species available in US markets. Several examples of state advisory
messaging are attached (see Appendix 1).
c) Specifically provide guidance about consumption of various species of fresh, frozen, and
packaged tuna (e.g., in cans and pouches) in the advisory, not just in the supplemental
Q & A, because tuna comprises a significant proportion of fish that Americans
consume.20
Charge 2: Based on currently available studies, is the draft advice on young children's
fish consumption appropriate?
In our review of currently available literature (see Appendix 2), the highest quality studies report
no consistent adverse neurodevelopmental effects in children, and several report a net benefit
in neurodevelopment associated with post-natal fish consumption.21"25 The body of evidence is
limited, however, and does not adequately investigate the balance between the risks and
benefits of post-natal fish consumption. In addition, we found worrisome evidence that
consumers may respond to advisories by reducing total consumption offish instead of switching
to lower mercury fish, leading to a net reduction in the health benefits of eating fish.26 In light of
these concerns and the limitations of the current evidence base, CHPAC recommends that
EPA:
a) Continue to include young children in this advisory as a public health protective measure
because of uncertainties about the risks posed by eating high mercury fish.
19 U.S. FDA. "A Quantitative Assessment of the Net Effects on Fetal Neurodevelopment from Eating Commercial
Fish (As Measured by IQ and also by Early Age Verbal Development in Children)". 2014 May.
20 U.S. FDA. "A Quantitative Assessment of the Net Effects on Fetal Neurodevelopment from Eating Commercial
Fish (As Measured by IQ and also by Early Age Verbal Development in Children)". 2014 May.
http://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/Metals/UCM396785.pdf.
21 SurkanPJ, Wypij D, Trachtenberg F, Daniel DB, Barregard L, McKinlay S, Bellinger DC. "Neuropsychological
function in school-age children with low mercury exposures". 2009 Aug. Environ Res: 109(6):728-33.
22 Cao Y, Chen A, Jones RL, Radcliffe J, Caldwell KL, Dietrich KN, Rogan WJ. "Does background postnatal
methyl mercury exposure in toddlers affect cognition and behavior?". Neurotoxicology. 2010 Jan. 31(1): 1-9.
23 Myers, GJ, Thurston SW, Pearson AT, Davidson PW, Cox C, Shamlaye CF, Cernichiari E, Clarkson TW.
"Postnatal exposure to methyl mercury from fish consumption: a review and new data from the Seychelles Child
Development Study". 2009 May. Neurotoxicology. 30(3):338-49.
24 Debes F, Budtz-Jorgensen E, Weihe P, White R.F, Grandjean P. "Impact of prenatal methylmercury exposure on
neurobehavioral function at age 14 years". 2006 Sep-Oct. NeurotoxicolTeratol. 28(5):536-47.
Plusquellec P, Muckle G, Dewailly E, Ayotte P, Begin G, Desrosiers C, Despres C, Saint-Amour D, Poitras K.
"The relation of environmental contaminants exposure to behavioral indicators in Inuit preschoolers in Arctic
Quebec". 2010 Jan. Neurotoxicology. 31(1): 17-25.
26 Teisl M, et al. "Awake at the switch: improving fish consumption advisories for at risk women". 2011. Science of
the Total Environment. 409:3257-3266.
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b) Carefully construct fish consumption advice to avoid the unintended consequence of
reducing children's fish consumption by:
• More strongly emphasizing the health benefits to children of eating fish,
• Encouraging children's consumption of fish lower in mercury, and
• Ensuring that the message is appropriate and accessible for low income, low literacy,
and non-English speaking communities.
c) Conduct a comprehensive literature review of the mercury risk and nutritional benefits of
children's fish consumption using a quality of evidence rubric.27
d) Support research that strengthens the evidence base to better understand the net
effects of children's consumption of fish. To reduce uncertainty, studies need to better
delineate the effects of mercury exposure and beneficial constituents like omega-3 fatty
acids in different fish species.
Charge 3: How should advice from local advisories for those who consume fish from
local streams, rivers, and lakes be integrated with this draft advice on mercury in fish?
CHPAC reviewed many state and local fish advisories to identify how they might be better
integrated with the federal advisory. Although states have traditionally focused on issuing
advisories on locally caught fish, some have now started to include advice on market fish.
Current EPA guidance for state fish advisories28 does not align with the joint EPA/FDA advice
resulting in confusion for consumers. For example, states generally follow the EPA approach to
develop fish advisories on market fish (e.g., several states already recommend avoiding orange
roughy and marlin when pregnant) while the EPA/FDA joint advice does not. To help assure that
fish advisories are as consistent, understandable, and influential as possible across a wide
range of audiences, CHPAC recommends that EPA:
a) Collaborate with FDA to ensure that approaches to developing national, state, and local
fish advisories provide consumers more consistent advice about local and market fish.
b) Improve the internet navigation from the federal advisory webpage to state and local
advisories webpages so that consumers can more easily access advisories on locally
caught and marketed fish. For example, the advisory could link to the interactive map on
the EPA webpage "Advisories where you live." EPA should work with states to fix broken
links and maintain accuracy of this important link to local advisories.
c) Review the effective use of color, graphics, icons, and professionally crafted messaging
that states, local governments, and tribes have developed to communicate fish
consumption advisories. These types of graphic enhancements, for both on-line and off-
line materials, would improve understanding of the federal advisory among consumers
and are essential in reaching low literacy populations and others who may not have
access to electronic media.
27 University of California, San Francisco Medical Center. "Program on Reproductive Health and the Environment:
Navigation Guide". 2009. http://www.prhe.ucsf.edu/prhe/navigationguide timeline.html.
28 U.S. EPA. "National Guidance: Guidance for Assessing Chemical Contaminant Data for Use in Fish Advisories.
Volume 2: Risk Assessment and Fish Consumption Limits - Third Edition". 2000 Nov. EPA. 823-B-00-008.
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Administrator McCarthy
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d) Fund and provide support for states, and other local health departments and tribes to
develop and disseminate advisories, tailoring messages and community engagement
activities for specific populations as needed.
In addition, CHPAC notes that other environmental contaminants can also accumulate in fish
and harm the developing fetus and child such as polychlorinated biphenyl compounds (PCBs)
which are known neurotoxicants. In the future, EPA should include guidance on other
environmental contaminants in the advisory based on the best scientific evidence available.
Thank you for your commitment to children's health.
Sincerely,
Sheela Sathyanarayana, M.D., M.P.H.
CHPAC Chair
Attachments
Appendix 1: Research Addressing Fish Advisory Information Dissemination
Appendix 2: Research Addressing Post Natal Fish Consumption
cc: Ruth Etzel, Director, Office of Children's Health Protection
Betsy Southerland, Director, Office of Science and Technology, Office of Water
Sharon Natanblut, U.S. Food and Drug Administration
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CHPAC Fish Advisory Letter to EPA:
Appendix 1
Research Addressing Fish Advisory Information Dissemination
Background
Many states use EPA guidance to develop green, yellow, and red lists of fish, based on how
much mercury they contain on average. Fish on the green list can be eaten 2-3 servings per week;
fish on the yellow list can be eaten 1 serving per week; and the red list should be avoided by
women of reproductive age and children. Figures 1 and 2, below, are two examples of guidance
developed by the Michigan Department of Community Health and the State of Washington.
Eat 8;S
A (.Utile to Help You Choose
Fish Low in Mercury from
Restaurants and Grocery Stares
Questions? Call MDCH at 1-800-648-6942.
SAFE TO EAT __k SAFE TO EAT
2-3 MEALS Gfr 1 MEAL
PER WEEK PER WEEK %
Follow this advice to reduce your exposure to mercury. PCBs, and other toxic chemicals: Women who are or may become
PREGNANT, NURSING MOTHERS.
v Anchovies
v Black sea bass
Butterfish
Catfish
Clams
Codas**
Crabau.tafto-
Crab- Imitation
Crayfish
Flounder/Sole
* Herring
* Mackerel****
» Oysters
Pollock/fish sticks
» Salmon M'.-w
v Chinook fee-
"Chumps ww
* Coho Sir
* Farmed*
* Pink***
» Sockeye**
~ Sardines
Scallops
Shrimp/Prawns
Squid/Calaman
T,lapw
v Trout
Tuna
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CHPAC Fish Advisory Letter to EPA:
Appendix 1
Additional Resources
Other state and local government agencies that have developed tiered guidance for the public
regarding fish consumption include:
• California Department of Public, Health Environmental Health Investigations Branch:
http://www.ehib.org/topics/CAPhvsAdvisoryChart 10 15 13.pdf
• California Environmental Protection Agency, Office of Environmental Health Hazard
Assessment: http://www.oehha.ca.gov/fish/pdf/201 ICommFishGuide color.pdf
• City of New York:
http://www.nvc.gov/html/doh/downloads/pdf/edp/mercury brochure.pdf
• Maine Center for Disease Control and Prevention:
http://www.maine.gov/dhhs/mecdc/environmental-
health/eohp/fi sh/documents/meffgui de. pdf
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CHPAC Fish Advisory Letter to EPA:
Appendix 2
Research Addressing Post Natal Fish Consumption
Cao Y, Chen A, Jones RL, Radcliffe J, Caldwell KL, Dietrich KN, Rogan WJ. Does background
postnatal methyl mercury exposure in toddlers affect cognition and behavior? Neurotoxicology.
2010 Jan;31(l):l-9. doi: 10.1016/j.neuro.2009.10.017. Epub 2009 Dec 5.
Cordier S, Garel M, Mandereau L, Morcel H, Doineau P, Gosme-Seguret S, Josse D, White R,
Amiel-Tison C. Neurodevelopmental investigations among methylmercury-exposed children in
French Guiana. Environ Res. 2002 May;89(l):l-11.
Davidson PW, Leste A, Benstrong E, Burns CM, Valentin J, Sloane-Reeves J, Huang LS, Miller
WA, Gunzler D, van Wijngaarden E, Watson GE, Zareba G, Shamlaye CF, Myers GJ. Fish
consumption, mercury exposure, and their associations with scholastic achievement in the
Seychelles Child Development Study. Neurotoxicology. 2010 Sep;31(5):439-47. doi:
10.1016/j.neuro.2010.05.010. Epub 2010 May 31.
Davidson PW, Myers GJ, Cox C, Axtell C, Shamlaye C, Sloane-Reeves J, Cernichiari E,
Needham L, Choi A, Wang Y, Berlin M, Clarkson TW. Effects of prenatal and postnatal
methylmercury exposure from fish consumption on neurodevelopment: outcomes at 66 months
of age in the Seychelles Child Development Study. JAMA. 1998 Aug 26;280(8):701-7.
Debes F, Budtz-j0rgensen E, Weihe P, White RF, Grandjean P. Impact of prenatal
methylmercury exposure on neurobehavioral function at age 14 years. Neurotoxicol Teratol.
2006 Sep-Oct;28(5):536-47. Epub 2006 Sep 1.
Donaldson SG, Van Oostdam J, Tikhonov C, Feeley M, Armstrong B, Ayotte P, Boucher O,
Bowers W, Chan L, Dallaire F, Dallaire R, Dewailly E, Edwards J, Egeland GM, Fontaine J,
Furgal C, Leech T, Loring E, Muckle G, Nancarrow T, Pereg D, Plusquellec P, Potyrala M,
Receveur O, Shearer RG. Environmental contaminants and human health in the Canadian Arctic.
Sci Total Environ. 2010 Oct 15;408(22):5165-234. doi: 10.1016/j.scitotenv.2010.04.059. Epub
2010 Aug 21. Review. Erratum in: Sci Total Environ. 2012 Aug l;431:437-8.
Echeverria D, Woods JS, Heyer NJ, Rohlman DS, Farin FM, Bittner AC Jr, Li T, Garabedian C.
Chronic low-level mercury exposure, BDNF polymorphism, and associations with cognitive and
motor function. Neurotoxicol Teratol. 2005 Nov-Dec;27(6):781-96.
Grandjean P, Budtz-j0rgensen E, White RF, J0rgensen PJ, Weihe P, Debes F, Keiding N.
Methylmercury exposure biomarkers as indicators of neurotoxicity in children aged 7 years. Am
J Epidemiol. 1999 Aug 1; 150(3):301-5.
Freire C, Ramos R, Lopez-Espinosa MJ, Diez S, Vioque J, Ballester F, Fernandez MF. Hair
mercury levels, fish consumption, and cognitive development in preschool children from
Granada, Spain. Environ Res. 2010 Jan; 110(1):96-104. doi:10.1016/j.envres.2009.10.005. Epub.
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CHPAC Fish Advisory Letter to EPA:
Appendix 2
Grandjean P, Weihe P, White RF, Debes F, Araki S, Yokoyama K, Murata K, S0rensen N, Dahl
R, J0rgensen PJ. Cognitive deficit in 7-year-old children with prenatal exposure to
methylmercury. Neurotoxicol Teratol. 1997 Nov-Dec;19(6):417-28.
Grandjean P, White RF, Nielsen A, Cleary D, de Oliveira Santos EC. Methylmercury
neurotoxicity in Amazonian children downstream from gold mining. Environ Health Perspect.
1999 Jul; 107(7): 587-91.
Hsi HC, Jiang CB, Yang TH, Chi en LC. The neurological effects of prenatal and postnatal
mercury/methylmercury exposure on three-year-old children in Taiwan. Chemosphere. 2014
Apr;100:71-6. doi: 10.1016/j.chemosphere.2013.12.068. Epub 2014 Jan 23.
Myers GJ, Thurston SW, Pearson AT, Davidson PW, Cox C, Shamlaye CF, Cernichiari E,
Clarkson TW. Postnatal exposure to methyl mercury from fish consumption: a review and new
data from the Seychelles Child Development Study. Neurotoxicology. 2009 May;30(3):338-49.
doi: 10.1016/j.neuro.2009.01.005. Epub
2009 Jan 21. Review.
Oken E, Radesky JS, Wright RO, Bellinger DC, Amarasiriwardena CJ, Kleinman KP, Hu H,
Gillman MW. Maternal fish intake during pregnancy, blood mercury levels, and child cognition
at age 3 years in aUS cohort. Am J Epidemiol. 2008 May 15; 167(10): 1171-81. doi:
10.1093/aje/kwn034. Epub 2008 Mar 18.
Plusquellec P, Muckle G, Dewailly E, Ayotte P, Begin G, Desrosiers C, Despres C, Saint-Amour
D, Poitras K. The relation of environmental contaminants exposure to behavioral indicators in
Inuit preschoolers in Arctic Quebec. Neurotoxicology. 2010 Jan;31(1): 17-25. doi:
10.1016/j.neuro.2009.10.008. Epub 2009 Oct 23.
Surkan PJ, Wypij D, Trachtenberg F, Daniel DB, Barregard L, McKinlay S, Bellinger DC.
Neuropsychological function in school-age children with low mercury exposures. Environ Res.
2009 Aug; 109(6):728-33. doi: 10.1016/j.envres.2009.04.006. Epub 2009 May 22.
Tavares LM, Camara VM, Malm O, Santos EC. Performance on neurological development tests
by riverine children with moderate mercury exposure in Amazonia, Brazil. Cad Saude Publica.
2005 Jul-Aug;21(4): 1160-7. Epub 2005 Jul 11.
Wang Y, Chen A, Dietrich KN, Radcliffe J, Caldwell KL, Rogan WJ. Postnatal exposure to
methyl mercury and neuropsychological development in 7-year-old urban inner-city children
exposed to lead in the United States. Child Neuropsychol. 2014;20(5):527-38. doi:
10.1080/09297049.2013.824955. Epub 2013 Aug 25.
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