Proceedings from the

2015 NIEHS/EPA
Children's Centers
Annual Meeting:

Protecting Children's Health for a Lifetime

U.S. Environmental Protection Agency
National Institute of Environmental Health Sciences

Washington, D.C.

October 29-30, 2015

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Disclaimer

This document has been reviewed in accordance with U.S. Environmental Protection Agency (EPA) policy
and approved for publication. Mention of trade names or commercial products does not constitute
endorsement or recommendation for use.

The National Center for Environmental Research (NCER), Office of Research and Development was
responsible for the preparation of this meeting report. Nica Louie served as the Task Assignment
Manager, providing overall direction and technical assistance, and is a contributing author/reviewer.
The proceedings were prepared by ICF International under contract with the U.S. EPA (contract number
EP-C-14-001). The document serves as a general record of presentations and discussions during the
meeting and captures the main points while highlighting discussions. It is not a complete record of all
details discussed, nor does it interpret or elaborate upon matters that were incomplete or unclear.
Statements represent the individual views of the workshop participants; except as specifically noted,
none of the statements represent analyses by or positions of EPA.

Reference herein to any specific commercial products, process or service by trade name, trademark,
manufacturer or otherwise, does not necessarily constitute or imply its endorsement, recommendation
or favoring by the U.S. Government. The views and opinions of authors expressed herein do not
necessarily state or reflect those of the U.S. Government, and shall not be used for advertising or
product endorsement purposes.


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UNITED STATES ENVIRONMENTAL PROTECTION AGENCY
NATIONAL INSTITUTES OF HEALTH

WASHINGTON, D.C.

National Institute of
Environmental Health Sciences

OFFICE OF

RESEARCH AND DEVELOPMENT

DIVISION OF EXTRAMUARAL
RESEARCH AND TRAINING

October 29, 2015

Dear Conference Participants:

It is our pleasure to welcome each of you to the 2015 NIEHS/EPA Children's Centers Annual Meeting.
We want you to know that it brings us much joy that children's environmental health advocates are
convening during children's health month. We are confident that your discourse will benefit children in
communities across the United States and beyond.

We are also inspired by the continued accomplishments from the Children's Centers program. Their
high-quality research findings have been instrumental in safeguarding children and reducing their health
risks from environmental exposures. We are delighted that this year's meeting builds on previous
partnerships with clinicians from the Pediatric Environmental Health Specialty Units. We have high
expectations that this meeting will further foster collaboration and lead to a greater understanding of
research successes and needs.

As we embark on 17 years of outstanding interagency collaboration, we recognize that we will all gain
strength and momentum by working together to protect the most vulnerable population - our children.

So once again, welcome and hope you enjoy the really exciting agenda that we have prepared for you!

Sincerely,

James H. Johnson. Jr., Ph.D.

Director

National Center for Environmental Research, EPA

Gwen W. Collman, Ph.D.

Director

Division of Extramural Research & Training, NIEHS


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Table of Contents

Meeting Summary	11

Session I - Welcome and Introduction	11

The Role of NIEHS in Supporting Children's Environmental Health - Linda Birnbaum	11

CDC/ATSDR's Role in Children's Environmental Health - Patrick Breysse	12

Children's Environmental Health: From Knowledge to Action - Ruth Etzel	13

Session I Questions, Answers, and Comments	14

Session 2 - Keynote	16

America Healing: A 21st Century Imperative - Gail Christopher	16

Session 2 Questions, Answers, and Comments	19

Session 3	20

Protecting Children's Health in the Future: Adapting to a Changing World - Thomas Burke	20

Session 4 - Social Determinants of Health	22

Asthma Disparities and the Indoor Environment - Greg Diette	23

Psychological Stress & Perinatal Programming of Chronic Disease - Rosalind Wright	25

Students Break the Cycle of Environmental Health Disparities - Leslie Rubin	27

CalEnviroScreen and Potentially Preventable Childhood Morbidity in California's Central Valley -
Emanuel Alcala	28

Session 4 Questions, Answers, and Comments	29

Session 5 - Lifestage Approach to Prematurity	31

The Life Course Perspective and Children's Environmental Health - Michael Lu	31

Session 5 Questions, Answers, and Comments	34

Session 6 - Neurodevelopmental Disorders	35

Lessons Learned From the New Bedford Cohort Study -Susan Korrick	35

The Long-Term, Brain-Based Effects of Prenatal Exposure to Two Environmental Neurotoxicants -
Bradley Peterson	37

It's about 4 Million Brains a Year - Toxic Chemicals and the In Utero Environment -

Tracey Woodruff	40

From Science to Policy: Targeting Environment and Neuro-Developmental Risks (Project TENDR) -
Irva Hertz-Picciotto	42

Session 6 Questions, Answers, and Comments	43

Session 7a - Obesity	45

The Contribution of Environmental Exposures to Childhood Obesity - Rob McConnell	45

Early Toxicant Exposures and Development of Child Obesity: Evidence and Gaps from Recent
Research - Karen Peterson	47

Environmental Health and Childhood Obesity: From Research to Action - Maida Galvez	49


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Session 7a Questions, Answers, and Comments	51

Session 7b - Exposome	52

Using a Risk Assessment Framework to Integrate Epigenetic Outcomes with Exposome Assessment
for Neurodevelopment - Elaine Faustman	52

High-Resolution Metabolomics for Sequencing the Exposome - Dean Jones	54

Environmental Exposures in Early Life Influence Childhood Leukemia - Stephen Rappaport	55

Session 7b Questions, Answers, and Comments	57

Session 7c - Reproductive Health	58

Updates on Environmental Effects on Reproductive Health - Marya Zlatnik	58

Impacts of Early-life Exposure to Endocrine Disrupting Chemicals on Puberty -John Meeker	59

The Pros and Cons of Testing Patients for Toxin Exposures -Susan Buchanan	60

Session 7c Questions, Answers, and Comments	62

Session 8 - Keynote	63

Little Things Matter: The Impact of Toxins on Children's Health - Bruce Lanphear	63

Session 8 Questions, Answers, and Comments	65

Session 9 - Community Outreach and Research Translation	67

Environmental Health Perspectives (EHP): Your Partner in Research Translation-Sally Darney	67

Why Are Doctors Talking Toxics? - Patrice Sutton	68

Do No Environmental Health Harm - An Updated Oath - Jennifer Lowry	69

Simplifying the Complicated: Leveraging Digital Media for More Effective Community Engagement
and Research Translation - Carolyn Murray	70

Build It and Will They Come? Lessons Learned from A Story of Health e-Book - Mark Miller	72

#duetoepigenetics #whatdoesthatmean #mustbevoodooscience - Susan Murphy	73

Session 9 Questions, Answers, and Comments	74

Session 10-The Pediatric Environmental Health Specialty Units Present: Emerging Topics in
Children's Health	77

A Blueprint for Protecting Children's Environmental Health: An Urgent Call to Action - Nsedu
Witherspoon	77

Potential Health Hazards of Increasing Cell Phone Use - Laura Anderko	78

Studies of Children's Exposure to Chemicals on Artificial Turf Fields - Gary Ginsberg	79

Not So Pretty - Endocrine Disrupting Chemicals in Cosmetics and Perfumes - Katie Huffling	81

Maternal Exposure to High Levels of Electromagnetic Fields (EMFs) During Pregnancy and the Long-
Term Health Impact on Their Offspring - De-Kun Li	82

Trends in Consumption of Artificial Sweeteners and their Metabolic Effects - Allison Sylvetsky	83

Children's Health Impacts of Climate Change - Perry Sheffield	84

Global Children's Environmental Health - Kathleen Alexander	85

Session 10 Questions, Answers, and Comments	86


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Session 11 - Next Steps for Collaboration between the Children's Environmental Health Centers and

the Pediatric Environmental Health Specialty Units	87

Overview of Pediatric Environmental Health Specialty Units- Ruth Etzel	87

How Pediatric Environmental Health Speciality Units and Children's Environmental Health Centers
Can Inform Children's Environmental Health Policy - Sheela Sathyanarayana	88

Preventing Childhood Leukemia: A Fruitful Partnership for Action - Catherine Metayer	90

Session 11 Questions, Answers, and Comments	91

Session 12 - Keynote	92

Adam Smith and the Business Case for Children's Environmental Health - Leonardo Trasande	92

Session 12 Questions, Answers, and Comments	97

Conclusions	98

Appendix A - Agenda	99

Appendix B - Speaker Biographies	105

Appendix C - Poster Session Abstracts	127

Appendix D - Participant List	151


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2015 NIEHS/EPA Children's Centers Annual Meeting

October 29-30, 2015

Meeting Suaaaaary

Session I - Welcome and Introduction

The Role of NIEHS in Supporting Children's Environmental Health

Linda Birnbaum, Ph.D. | Director, National Institutes for Environmental Health Sciences (NIEHS)

Dr. Linda Birnbaum kicked off the 2015 NIEHS/EPA Children's Centers Annual Meeting and welcomed the
participants. She explained that the mission of NIEHS is to understand how the environment impacts
human health in order to promote healthier lives. Specifically, for children, it is important to give them
the healthiest start possible and the tools to maintain a healthy lifestyle throughout their lifetime.

Dr. Birnbaum provided an overview of the NIEHS budget for children's environmental health and
identified the priority research areas. In fiscal year (FY) 2014, the most recent year for which budget data
are available, NIEHS gave over $115 million in grants for research to explore children's environmental
health in the following 15 areas: neurological/cognitive outcomes, birth outcomes, cardiovascular
outcomes, respiratory outcomes, metabolic outcomes, cancer outcomes, reproductive outcomes,
immune outcomes, liver outcomes, thyroid dysfunction, skin, morbidity/mortality, musculoskeletal
outcomes, and microbiome outcomes.

Dr. Birnbaum went on to outline the goals of the NIEHS/EPA Children's Centers, which are to better
understand the factors that influence children's environmental health; promote multi-disciplinary
interactions by including clinical, public health, and basic science research; turn research into real-world
treatments and interactions; establish a national network of children's environmental health experts; and
provide community outreach and translation.

Dr. Birnbaum discussed the path forward for NIEHS and EPA collaboration on children's environmental
health, which includes five new Children's Centers that will be announced in December 2015. She noted
that NIEHS is also responsible for redistributing the funds intended for the now-defunct National
Children's Study. These funds will be used to achieve three main goals: develop tools to measure
environmental exposures in children's health research, enhance the understanding of in-utero and
postnatal development, and leverage existing programs. Dr. Birnbaum discussed the development of tools
to measure environmental exposures in detail, using the Children's Health Exposure Analysis Resource
(CHEAR) as an example. CHEAR aims to expand the number of studies with environmental exposure
analysis, implement the exposome concept in children's health studies, create a public resource of
children's exposures across the country, and develop data and metadata standards for the environmental
health sciences community. CHEAR is comprised of a National Exposure Assessment Laboratory Network
where the actual exposure analyses are conducted. The Network will focus on conducting both targeted

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and untargeted exposure analyses, measuring biological response indicators, and developing and
validating new exposure characterization methods. CHEAR is also comprised of a Data Repository,
Analysis, and Science Center, which will store exposure data and provide analytical support to exposure
scientists. The CHEAR Coordinating Center will deliver overall administrative management.

Dr. Birnbaum discussed NIEHS-funded extramural environmental epidemiology resources, noting that in
FYs 2013 and 2014 alone, this involved 58 studies. Specifically, this includes 50 cohort studies, six case
control studies, and two cross-sectional studies. The cohort studies included assessment of 20 birth
cohorts, 15 child/adolescent cohorts, and three reproductive health cohorts. She also pointed out that
individual studies have a project details page that is publicly available through the NIEHS website.

As for next steps, Dr. Birnbaum highlighted the Agency's intentions to enhance the inventory of existing
birth cohorts with additional detail and linked grants; promote the use of CHEAR; implement the
exposome concept in children's health research; and create a program to maintain environmental health
cohorts and promote the use and sharing of extant data. The latter will be implemented through the new
Environmental Influence on Child Health Outcomes (ECHO), a program being established by NIH.

CDC/ATSDR's Role in Children's Environmental Health

Patrick Breysse, Ph.ID. || Director; National Center for Environmental Health/Agency for Toxic Substances
and Disease Registry (ATSDR), Centers for Disease Control (CDC)

Dr. Patrick Breysse presented on the role of the CDC/ATSDR in children's environmental health. He
explained that the mission of NCEH/ATSDR is to "protect people's health from environmental hazards that
can be present in the air we breathe, the water we drink, and the world that sustains us" by investigating
the relationship between environmental factors and health, developing guidance, and building
partnerships to support healthy decision making. He highlighted the NCEH/ATSDR priorities, which include
reducing asthma morbidity and mortality; protecting children from the health risks of harmful exposures
and conditions; ensuring safe drinking water; and using innovative laboratory methods to detect,
diagnose, and prevent environmental disease. Specifically, NCEH/ATSDR works to protect children from
the health risks of harmful exposures by:

•	Implementing a national strategy to protect children from harmful exposures related to daycare
and early learning centers;

•	Implementing a nationwide education campaign to protect children from exposures to mercury
and promote recovery of mercury from schools, homes, and abandoned facilities;

•	Using laboratory testing, modeling, and data systems to collect and analyze data describing
children's exposure;

•	Preventing children's exposure to environmental health concerns such as lead, vapor intrusion,
and carbon monoxide;

•	Building the skills of health care providers and emergency responders regarding children's
vulnerabilities to harmful exposures; and

•	Ensuring that children are considered in land-use and transportation health impact assessments
(HIAs).

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Dr. Breysse discussed in detail several NCEH/ATSDR programs intended to protect children against the
harms of environmental exposures:

Childhood Lead Poisoning Prevention Program. He noted that four million U.S. households have children
that are exposed to high levels of lead and approximately half a million children ages one to five years
have blood lead levels above the CDC's reference value of five ng/dL. Dr. Breysse stated that the program
will fund the reestablishment of blood lead surveillance efforts on the state and local level, which will
involve collecting and analyzing data to identify the highest risk areas. The program will continue to help
reduce childhood lead poisoning, reduce associated health care costs, and improve academic
achievement and later-life success for at-risk children.

National Biomonitoring Program. The National Biomonitoring Program, which functions as part of the
National Health and Nutrition Examination Survey (NHANES), samples a subset of the NHANES study
population to assess exposure to priority environmental chemicals. The broader goal of the program is to
provide the laboratory science that improves the diagnosis, treatment, and prevention of disease resulting
from exposure. He displayed results of an analysis of NHANES data that shows the decrease of certain
phthalates overtime. He noted that this highlights the shifting practices of the chemical industry that may
imply the need for updating research hypotheses or changing the focus of funding.

National Asthma Control Program. The program promotes collaboration between the health care
industry and public health communities relative to asthma focusing on infrastructure, services, and health
systems.

National Environmental Public Health Tracking Network. This network is an online system of exposure
and response data and information intended to enable public health officials to respond quickly to specific
inquiries about risks. Data specific to children include asthma, biomonitoring, childhood cancers, lead
poisoning, developmental disabilities, heat vulnerabilities, and pesticide exposures. To illustrate the
capabilities of the National Environmental Public Health Tracking Network, he displayed maps of asthma
hospitalizations by county in the state of Florida for two age groups and a map showing the incidence of
childhood leukemia by state. The data can be used for descriptive or analytical purposes.

Pediatric Environmental Health Specialty Units (PEHSUs). The PEHSUs advise pediatricians and families
on treating and protecting children potentially exposed to harmful chemicals and address the health risks
children face from environmental hazards like lead, mercury, mold, plastics, and pesticides. He noted that
these programs are key in protecting and promoting children's health.

Children's Environmental Health: From Knowledge to Action

Ruth Etzel, M.D., Ph.D. || Director, Office of Children's Health Protection, U.S. EPA

Dr. Ruth Etzel discussed how EPA implements children's environmental health science data in the
regulatory context. She began by noting the annual presidential proclamation on children's health during
Children's Health Month. This year, President Obama explicitly included the implications of climate change
on children's health and the importance of coordinating action at the national and international levels.
Dr. Etzel also highlighted several of EPA's Children's Health Month events, which included a meeting

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hosted by the newest PEHSU in El Paso, Texas to discuss environmental health issues for children living
along the United States/Mexico border; an EPA open house showcasing the Agency's accomplishments
during the 20 years since the implementation of the 1995 Policy on Evaluating Health Risks to Children;
and a meeting of the President's Task Force on Environmental Health Risks and Safety Risks to Children,
which includes 17 Federal Agencies, Office and Departments. During the President's Task Force meeting,
Co-Chairs U.S. EPA Administrator Gina McCarthy and Department of Health and Human Services (HHS)
Secretary Sylvia Mathews Burwell reviewed the Task Force's actions addressing children's environmental
health issues such as asthma disparities, healthy homes, chemical exposures, and climate change.

A recent success in children's health protection is the updated Agricultural Worker Protection Standard,
which includes provisions that protect children. Specifically, it requires that pesticide handlers and early-
entry workers must be at least 18 years old, whereas there was no minimum age prior to the 2015 update.
Progress on preventing pesticide poisonings has been supported by health effects research results from
cohort studies conducted at three NIEHS/EPA Children's Centers: the Center for Health Assessment of
Mothers and Children of Salinas (CHAMACOS) cohort, the Columbia University cohort, and the Mount
Sinai cohort.

Another success in promoting children's health that Dr. Etzel discussed was the new air quality standard
for ground-level ozone. She noted that the National Ambient Air Quality Standards (NAAQS) for ground-
level ozone have been strengthened to 70 parts per billion (ppb), which is estimated to translate to
between $2.9-5.9 billion in health benefits in 2025. Of particular note, the new standard will avoid an
estimated 230,000 childhood asthma attacks, 160,000 missed school days, and 340 cases of acute
bronchitis among children.

Session I Questions, Answers, and Comments1

Jennifer Lowry, Region 7 PEHSU, stated that she was involved in the REACH program at University of
California, San Francisco (UCSF). One project within the REACH program is focused on integrating
environmental data sets with those at EPA. She recognized that this would be a complicated, but
worthwhile, effort. Patrick Breysse agreed, saying that he, Tom, and Ruth have discussed how to better
integrate information across data systems. They are being told by Congress that each of their agencies
must be more efficient in their data gathering efforts in order to reduce the burden on states and local
governments. They are planning to talk further about this effort. Tom Burke added that there is a big push
to make this happen as it is a natural potential marriage of the analytic tools and community-based tools.
In the era of HIAs and tracking, there is huge incentive to move that forward. Patrick Breysse agreed,
saying they need to identify the things that are best suited for integration and move forward.

Natalie Grant, U.S. HHS, inquired about how they might be able to utilize these integrated data sets to
inform and support post disaster community decision-making (when funding is available) where multiple
environments and exposures to hazards exist. She wondered how to apply the best available data to

1 Due to last minute changes to the agenda, Dr. Tom Burke presented as part of Session 1, and participated in the
panel discussion. Please see Session 3 (pg 18) for a summary of his presentation.

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community-level planning processes in a way that local residents can easily understand, recognizing that
there is limited capacity to have those analytics done. Linda Birnbaum mentioned that NIEHS with
colleagues from EPA and CDC developed a program called the Disaster Research Response Project (DR2).
She added that when there is an emergency, steps need to be taken to protect public health and often
research must be conducted to identify what the community needs. This can be very difficult to do, and
it can be challenging to get into the field rapidly. On the HHS website, there is a lot of information on what
needs to be done when responding to emergencies; approved protocols for collecting data are also
available on the National Library of Medicine website.

Sue Kiridly, Cohen Children's Hospitalsaid her son had a rare tumor in his lungs, and what she discovered
during that process was that our country does not have a cohesive children's rare tumor registry, which
was mind-boggling to her because other countries (e.g., the UK, Germany, and South Africa) do have one.
In the United States, some institutions are obligated to report rare tumors, and some are not. Sue stated
that she thinks that the most important thing for children's cancer research as well as research for other
environmental health concerns is to develop a process for getting the correct numbers. She asked, "How
can we move forward without numbers that encompass everyone?" Ruth Etzel agreed, acknowledging
the huge gap that needs to be addressed in order to put prevention into place. She stated that there are
no reliable data on rare childhood cancers—which we know probably have environmental influences—
and that this is something on which federal agencies can collaborate. Linda Birnbaum commented that
NIH does a lot of work related to rare tumor research and that it is currently instituting a very stringent
policy related to reporting of clinical trials. Negative findings are often not reported or they are not
reported in a timely manner. She believes this issue is related to medical practice that is changing where
results—whatever they may be—will be broadly available online. An individual from EPA Office of Solid
Waste and Emergency Response asked whether the panel had any specific resources regarding children's
health for offices like Superfund that primarily deal with regulations and guidance. Tom Burke said that,
from an EPA perspective, Superfund has done great things, but they need to work on their formulaic
approach to understanding community risk by looking at a broader range of exposures, pathways, and
impacts. Patrick Breysse said that on the ATSDR website, they are challenged to provide community
education through toxicological profiles and community accessible translation of these profiles. He thinks
they can do better. Linda Birnbaum mentioned that NIEHS has been funded specifically to deal with
Superfund issues, and they partner with EPA and ATSDR to address issues of concern, many of which
involve children cohorts and community outreach.

Tenya Steele, Center for Environmental Health, referred to Tom Burke's presentation where he discussed
the difficulty of using new science to update risk assessments. She asked if processes are in place to push
through those difficulties and if there are any concrete plans to update those risk assessments. Tom Burke
answered yes, saying risk assessment has been an important decision-making tool, but it is often focused
on one exposure medium or one type of individual, and that we have evolved to understand the
contributions to risk beyond those factors. Cumulative risk is really challenging; when thinking in the
context of a Superfund site, there are many factors that affect risk. They are pushing forward with risk
assessment and problem formulation to ensure the right questions are being asked upfront. Dr. Burke
said they are also complimenting risk assessment with other approaches like HIAs and baseline
assessments of community health, and trying to improve exposure assessment. He said he wished funding

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included exposure/dose characterization from a biomonitoring perspective. While they are pushing
forward in a number of ways, it is hard to move to policy without the help of researchers. Patrick Breysse
stressed the importance of working together closely. Risk assessments are often limited in what they can
say, in part because data that inform them are limited. They are thinking more about what types of data
to collect, the characterization process, and how to use risk assessment to inform communities about
broader health impacts. They are working to identify critical areas of data collection that the EPA can help
early on so that the process will work better. He said they are working more closely with EPA to bridge
those gaps.

Session 2 - Keynote

America Healing: A 21st Century Imperative

Gail Christopher, D.N. | Vice President of Policy and Senior Advisor, W.K. Kellogg Foundation
Moderated by Kari Nadeau, M.D., Ph.D. | Stanford University

Dr. Gail Christopher began with a reminder that modern society has multiple sectors, each privileged and
constrained by various factors. The philanthropic sector has historically tried to catalyze fund innovation
and creativity, and to help frame the discussion to move agendas forward. The founder of the W.K. Kellogg
Foundation said, "Do what you will with the money so long as it helps children." His primary concern was
the well-being of "vulnerable children." Over 80 years ago, he recognized that children of color, and
particularly children with disabilities, faced barriers to their success. More than 70 years later, the W.K.
Kellogg Foundation revisited its mission. Taking an innovative approach to addressing these barriers
accelerated the founder's mission, because most children born in the United States today are children of
color, and most are from low-income families in impoverished communities. The Foundation believes it is
in the best interest of the country to increase their investments and ensure all children face fewer barriers
to success. This led them to the bold decision to become "the most effective anti-racist organization they
can be," with an explicit and direct focus on issues of racism. After a decade of having this explicit focus,
Dr. Christopher shared that the Foundation has learned greater resilience and interventions supported by
research that can make a critical difference in children's lives. She believes it complements some of the
work conducted at Children's Centers and other child-focused research and initiatives.

As several movements in the public health field converge, Dr. Christopher said it is uncommon to be in a
public health meeting that does not reference social determinants of health (SDoH). The World Health
Organization (WHO) defines SDoH as the circumstances in which people are born, grow up, live, work, and
age, and the systems put in place to deal with illness. SDoH include factors such as access to affordable
healthy food, clean water, green space, safe housing, clean air, and supportive social networks. These
circumstances are shaped by the distribution of money, power, and resources and are impacted by
biological, chemical, and social factors resulting in inequities in disease burdens, health, and quality of life.
Children have unique vulnerabilities to all forms of adversity within their environments. Non-chemical
SDoH can exacerbate or mitigate related risks and exposures. Public health conversations now include the

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life-course perspective and exciting discoveries from the field of epigenetics. Consensus is emerging
around adverse experiences in childhood, and how they predispose children to greater risk for chronic
disease and substance abuse later in life. Dr. Christopher remarked that the environment, in both a macro
and micro sense, is perhaps the most determining factor in terms of the opportunity to be healthy and to
thrive.

Dr. Christopher described how the Foundation has integrated the SDoH framework into their funding
effort, focusing on food health and well-being, education and learning, and family economic security. The
Foundation has been involved in the health care reform space for about ten years, and many of their
investments contributed to bringing about the Affordable Care Act. Around 2007, the Foundation was
interested in applying the SDoH framework to support communities in their efforts to mitigate excessive
exposures to negative social determinants. They focused on young children to close gaps in infant
mortality and other disparities, and concentrated resources in specific geographic areas around the
country. Funded interventions in Michigan resulted in no infant mortality and no low birth weight within
a high-risk group of teenage mothers over a four-year period, validating these social interventions.
Another example is the "centering pregnancy" model, in which the mother gets support throughout the
pregnancy in small groups. They found that companion care, companionship, and social networking with
human interaction reduces stress levels and improves birth outcomes. The Foundation has also put
resources into optimizing breast feeding rates, and increasing baby-friendly hospitals, which previously
did not exist in low-income, high-risk communities. They have invested $15 million to help accelerate the
movement of medical facilities within communities that adhere to guidelines to optimize breast feeding
rates and have observed dramatic increases in initiating as well as sustaining breast feeding over time. All
of these interventions were based on the science and done in partnership with the public sector and
academia.

It has been difficult getting other foundations on board. Even though the breast feeding optimization
movement is a relatively low-cost intervention that can change the outcomes of at-risk populations, it
continues to face pushback and resistance. Dr. Christopher shared examples of these specific
interventions, which do not directly confront the issues of America's embedded belief in racial hierarchy
or racism, because the Foundation's approach includes both. Although they need to work on changing
hearts and minds and uprooting the 18th century belief in a hierarchy of human value, it is also necessary
to put in place tools communities can use to help mitigate the unnecessary exposures they face on a daily
basis.

The Foundation is also working to optimize access to quality food in communities by funding the food
systems change movement, among other initiatives. The Foundation has partnered with the White House
Partnership for a Healthier America, Trust for America's Health, the school food movement, and other
food groups. The paradigm starts with first food and breastfeeding, then moves to early food, and later
to school food, which has the greatest traction. One example is the Farm to School movement, which
gives schools access to fresh vegetables. Research demonstrates that when the diet is predominantly fresh
vegetables, many inflammatory markers, along with the subsequent risk for chronic disease, are greatly
reduced. Emerging science validates the importance of the holistic approach, yet communities that need
it the most have the least access. Dr. Christopher said at least 50 foundations are actively engaged in food

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systems work to change this, but they need the help of the children's health research community to
document the relationship between healthy diets and mitigating the effects of overexposure to
environmental toxins. The Foundation also is working to bring the conversation about lead back into the
mainstream public and environmental health conversation. In partnership with EPA, the Foundation
recently funded the publication of a guide for communities to help school systems test lead levels in
drinking water, as many still have these antiquated systems that provide unnecessary lead exposure.

Dr. Christopher then discussed what she referred to as "the bravest thing our Foundation has done,"
which is to say all of the things discussed, including disparities in income and exposure, are in fact a
symptom of a much deeper societal challenge we all face. The Foundation calls it a 21st century imperative;
the challenge to move beyond denial of the fact that this country was not conceived in liberty, but in the
false ideology of a hierarchy of human value. This concept was created in the 1700s, about the time the
printing press proliferated, and found its way into the literature, the canon, and the consciousness of a
nation becoming. Dr. Christopher described a belief that some people are more deserving that others
based on their physical characteristics as part of the DNA of the United States. This mindset dominated
the nation's consciousness for more than two and a half centuries and was embedded in the U.S.
Constitution and throughout the country, not just in the South. The country had a Civil War and
Reconstruction, and 50 years later had a civil rights movement, and subsequent to that movement, has
experienced continuous backlash to turn that back. Both efforts were designed to address the
consequences of this belief, but the belief itself has never been addressed in a straightforward way, nor
has a campaign and a decision been made to uproot that belief. She asked the audience to imagine a
country not characterized by residential segregation comparable to South Africa at the heart of apartheid
and one in which school systems are equally funded, access to quality health care is not based on zip code,
and zip code is not more important than genetic code. Dr. Christopher said she is proud to be part of a
foundation that has invested more than $200 million in helping communities over the last decade, in an
inclusive and straightforward way, challenging racial hierarchy. The Foundation has funded research in
the area of bias and unconscious bias to allow professions and disciplines to offer training to help
individuals, such as law enforcement officers, confront their biases and see how those biases shape their
behaviors. The idea that humans are unconsciously programmed to adhere to the false concept of a
hierarchy of value is a very viable idea that individuals can embrace without triggering shame, guilt, anger,
and other emotions that prevent them from confronting the concept. The unconscious bias work needs
to be implemented in every institution to avoid serious implications down the road. Just as the concept
of a racial hierarchy proliferated during the first information revolution, these algorithms will perpetuate
the same divisions if people do not intervene now. The manifestations of this belief system can be
observed in the criminal justice system, as a consequence of that information revolution (e.g., cell phone
cameras). Dr. Christopher then asked: How can people harness that opportunity and really make a
difference in humans' capacity to relate to and appreciate one other as equals?

Turning to a discussion of equality versus equity, Dr. Christopher explained that racial equity refers to
principles of fairness and justice. Racial equity work describes actions designed to address historic burdens
and remove present day barriers to equal opportunities. Identifying and eliminating systemic
discriminatory policies and practices with specific remediating strategies accomplishes this. These actions
address the effects of historic injustice and prevent present and future inequities. In terms of equality,

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philosophically, the Foundation is addressing the embedded false notion that there is a gradation of lesser
value based on physical characteristics. The human genome makes it very clear that humans are 99.9
percent the same. Although some might use it as a basis for perpetuating the belief in racial hierarchy,
the evidence is clear that there are more differences within the socially constructed races than between
them. These adaptions and physical characteristics are consequences of how our ancestors evolved to
adapt to their environments.

Dr. Christopher then discussed the environmental justice movement and applauded efforts to increasingly
incorporate it into EPA's work. Environmental justice is responsive to Executive Order 12898 to address
inequities in the distribution of environmental hazards rather than addressing the broader context and
root causes of such inequities. She argued the necessity of connecting the environmental justice paradigm
and SDoH framework to consider resilience. Environmental exposure to toxic chemicals is one of many
SDoH. The impact of such exposures can be influenced by non-chemical stressors and exposures or
reduced access to needed resources, such as quality health care. Housing segregation, poverty, and civic
engagement can shape the levels of risk and protections available to families within their communities.
Cumulative exposure fits with the emerging paradigm around trauma and adversity. Looking at the body
holistically, and seeing the pathways involved with inflammation and adaption, it is evident that they all
fit together. Thus, it is important to educate and intervene to help people minimize the risks they are
facing, both from a standpoint of chemical and environment risks in terms of trauma and adversity. The
Foundation helped to fund a commission called the Courage to Love, which focused on the gap in terms
of infant mortality and the degree of low birth weight outcomes experienced in communities where
women faced disproportionate levels of discrimination. In terms of the excess exposures facing children
of color, researchers have coined the term double jeopardy, which children experience when they live in
both poor families and poor neighborhoods.

Moving forward, Dr. Christopher emphasized the importance of incorporating the private sector into this
discussion. The Foundation funded a study called the "Business Case for Racial Equity," as they argue there
will not be significant changes in terms of SDoH until the private sector is involved. The inequities of today,
left unchecked, will yield even more harm to our nation's children tomorrow, especially to minority
children. A mother of color, no matter her education, faces a greater risk for low birth weight and higher
infant mortality than a white mother that has not finished high school. Dr. Christopher concluded her talk
with an invitation to join the effort. The Foundation believes the recent changes in public awareness of
the need for the United States to address racism has led society to an unprecedented point in time. The
Foundation will be accelerating its investmentto bring about an adaption of the internationally recognized
approach to healing from a historic past: truth and reconciliation. They believe it is truth, racial healing,
and transformation for this country that is part of bringing about environmental justice and equity.

Session 2 Questions, Answers, and Comments

Alan Woolfe, Boston's Children's Hospital/Harvard, applauded Dr. Christopher and the incredibly
important work the Foundation is doing. He asked her to comment on the role of the Foundation and
others in extending the work to students in schools of medicine and public health and teaching hospitals.

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Given the need to make racial and ethnic discrimination in healthcare an explicit curriculum to give
students and trainees a safe environmentto approach a dialogue about increasing awareness of their own
biases, he wondered how we can work together to eliminate disparities in healthcare. Dr. Christopher
referred to her colleagues who have done brilliant work on documenting the racial disparities in terms of
treatment options, not just access, which reflects unconscious bias. She felt that not enough was being
done and hoped that the Foundation's new effort around truth and transformation will result in an
examination of every major system in the country, inserting tools and resources for change. She reiterated
that this is change at an individual level as well as an institutional level, so in addition to an explicit
curriculum, she recommended a tool, the Intercultural Development Inventory, which allows individuals
to assess where organizations and individuals are on a continuum. As none of us are without bias, Dr.
Christopher emphasized the importance of tracking and identification and using resources and tools to
overcome it, especially in systems where people are making life and death decisions.

Dr. Christopher recommended the books Black Man in a White Coat and Sick from Freedom.

Another audience member said U.S. EPA's ORD was looking to possibly support SDoH research, and asked
Dr. Christopher how the picture would look if she was to focus on factors related to environmental
components of SDoH. Dr. Christopher said the traditional models included healthy housing, proximity to
toxins, and waste dumps. She believes more research is needed to document the biological and
biochemical pathways that are engaged when we are exposed to discrimination. There is a study coming
from Massachusetts where the researcher worked with second generation descendants of Holocaust
survivors. She found differences in the stress responses of the grandchildren of survivors, in terms of a
generational effect of exposure to trauma. Researchers have not even begun to ask the questions about
all the communities that have had disproportionate exposure to continuous trauma based on
environmental inequities. Dr. Christopher would ask that the investigation of the environment include
interpersonal dynamics and exposure to individual and systemic racial discrimination.

Session 3

Protecting Children's Health in the Future: Adapting to a Changing World
Thomas Burke, Ph.D. | Science Advisor, U.S. EPA

Dr. Thomas Burke began by saying how terrific it is to have this opportunity to reach across institutional
barriers in the policy making process. He asked the audience, "What is the most important thing we can
do together to protect and promote children's health from an environmental health perspective?" In his
view, we need to improve the application and understanding of our science, improve the trust and
credibility of our science, and make more effective changes to policies to protect public health, particularly
for our children.

Dr. Burke applauded U.S. EPA Administrator McCarthy as an advocate for children's health. The
fundamental mission of the EPA is to protect the health of the public, and protecting children's health is

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a critical part of that mission. It is important to apply the science as best as possible and defend it against
challenges.

Dr. Burke described the timeline and progress of the EPA over the last few decades. Pre-1990, exposure
was oversimplified: Everyone was a 70 kg man who drank two liters of water a day, never breast-fed,
never ingested soil, and hung out on a porch for 30 years. In the early 1990s, changes were occurring to
better characterize exposure. In 1993, the National Academy of Sciences published a groundbreaking
report, Pesticides in the Diets of Infants of Children, which illustrated the importance of diet-related
exposures. The Food Quality Protection Act of 1996 also addressed childhood exposures. Since President
Clinton's Executive Order in 1997, children's health has moved to the forefront of exposure assessment.
Today, research conducted at Children's Centers has provided federal, state, and local decision makers
with vital information for making better-informed decisions that are more protective of children's health.
Columbia Children's Center research informed a landmark environmental health law in New York City that
required the use of integrated pest management (IPM) in public housing. A related law required that
residents are notified 24-48 hours in advance of pesticide application in a neighboring property. The
University of Washington Children's Center demonstrated that farmworkers were not the only receptors
exposed to the pesticide azinphos-methyl in the fields. The workers were also bringing the contamination
home where it built up in house dust; correlations were found between pesticide levels in house dust and
child resident pesticide levels. This evidence was cited in EPA's decision to ban that pesticide by 2011. It
is important that we continue to increase our understanding of childhood pathways to exposure in order
to develop a broader approach to protecting children.

Dr. Burke discussed the biggest problems ahead given environmental challenges and evolving science.
Old-school environmental science was fragmented and compartmentalized; regulations focused on one
thing at a time, and often scientists were trained in a single discipline. Today, scientists face difficult
challenges (e.g., drought and climate change) that cut across multiple disciplines. Understanding within
and across compartments is essential and consideration of emerging technologies, new understandings
of the science, energy aspects, and community design factors is needed. Dr. Burke discussed his role in a
National Academy of Sciences panel, Science for Environmental Protection: The Road Ahead, which looked
at the evolution of environmental health science challenges. The challenges associated with
environmental protection today are complex, often affected by many interacting factors. There are
various spatial and temporal scales to consider; many environmental health issues have global
implications. Some of these environmental challenges are difficult to define and are variable and socially
complex with no clear solution or end point, and many extend beyond the understanding of one discipline.
Dr. Burke believes that it is important to train people to deal with these complex issues and to work
together to address them. At EPA, the sources-to-effects continuum (i.e., understanding the
environmental concentration, exposure of a population, and health outcome) has been a basis of their
work and represents one of the biggest challenges in epidemiology and risk assessment. Environmental
public health tracking is key to conducting HIAs. This tracking follows a linear toxicology/epidemiology
model of hazard: understanding of presence in the environment, route of exposure, host exposure, target
tissue, adverse effect, and outcome of interest. The epidemiology triad denotes that health status
depends on host factors, agent characteristics, and environment; dose is not the only important factor.

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The challenge is to understand how these factors interact. Dr. Burke questions whether past approaches
are sufficient to address today's "wicked problems."

In order to solve today's "wicked problems," society needs to understand the context of the problem;
dimensions of a problem; and connections between ecosystem factors and human health. Our economy
and human health and well-being cannot function without a healthy ecosystem. Health is not just about
health care. Moving forward, Dr. Burke believes the following data and tools are critical to informing
exposure assessment: thorough up-front problem formulation and scoping; systems approaches and
tools; techniques and tools to integrate different types of data from multiple disciplines (e.g., ecological
risk, human health risk, social sciences); new technologies (e.g., high throughput chemical screening);
novel techniques (e.g., citizen science, which provides new sources of information and insights into
exposures); science translation to address challenges of using evolving science to update old standards.

The public health problem-solving approach comes from an instrumental paper in children's health,
written by Bernie Guyer discussing what public health is all about. The general approach outlined in this
paper consists of defining the problem; measuring the magnitude of the problem (using surveillance,
hazard identification); developing a framework for key determinants (e.g., biologic, epidemiologic, social,
cultural, economic, political); using research translation to identify and develop intervention and
prevention strategies; setting priorities and recommending policies; implementing programs; and
evaluating health outcomes. Dr. Burke concluded by saying that the Children's Centers have provided
some of the groundwork and research needed to move forward in implementing new approaches for
solving tomorrow's challenges in children's health—for example, use of multidisciplinary approaches;
consideration of nonchemical stressors and social factors; efforts in translation/outreach; and focus on
intervention/prevention—and this work needs to continue.

Session 4 - Social Determinants of Health

Moderated by Andrew Geller, Ph.D., M.A. | Deputy National Program Director, Sustainable and
Healthy Communities Research Program, U.S. EPA

Dr. Andrew Geller thanked the previous session speakers for a great opening session and introduced the
social determinants panelists: Dr. Rosalind Wright, from the Icahn School of Medicine at Mount Sinai who
discussed psychosocial stress and perinatal programming of chronic disease; Dr. Greg Diette, from Johns
Hopkins University, who discussed asthma disparities and the indoor environment; Dr. Leslie Rubin, from
Morehouse School of Medicine, who discussed how students break the cycle of environmental health
disparities; and Mr. Emanuel Alcala, from Central Valley Health Policy Institute, who discussed
CalEnviroScreen and Potentially Preventable Childhood Morbidity in California's Central Valley.

EPA is considering community stressors in discussions for incorporating chemical and nonchemical
stressors in cumulative risk assessments, specifically how their interactions with biologic systems and
environmental exposures result in adverse health effects and health disparities. EPA considers these
factors important to consider in cumulative risk assessments and current knowledge about applications

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of community stressors points towards including social determinants as critical factors in assessments
used to set regulatory limits. Many social determinants of health are potentially modifiable factors that
may be affected by changes in individual behavior, policy, and community infrastructure.

Dr. Gail Christopher did an excellent job introducing the social determinant factors that should be
prioritized, and EPA's Children's Health Protection Advisory Committee (CHPAC) identified a number of
candidate factors in their letter to EPA, including quality of education, access to healthy food, access to
health providers, breastfeeding, transportation conditions, housing conditions, segregation, income, and
civic engagements, among others. Another way to examine these factors is presented in EPA's Draft
Environmental Justice Technical Guidance document. EPA is considering the possibility that these societal
factors come from a false hierarchy of human values and that the social stratification themselves are a
function of multiple societal and political factors that shape social determinants of health. Dr. Geller
stated his own personal bias that he feels strongly that children's environmental health and
environmental justice have deeply converging interests and noted his enthusiasm about the inclusion of
social determinates of health in EPA's environmental justice roadmap.

Dr. Geller challenged meeting participants to consider other actions that emerge from our knowledge of
social determinants of health such as decision contexts or other areas to which social determinants of
health information can be critically important. He asked participants to examine the social determinant
factors being considered, being missed, should be prioritized, and what actions should be taken moving
forward for understanding prioritization. Dr. Geller introduced the first panelist, Dr. Greg Diette, from
Johns Hopkins University, who researches diet and home modification and health disparities in the home
environment.

Asthma Disparities and the Indoor Environment

Greg Diette, M.D. || Johns Hopkins University

Dr. Greg Diette explained that his presentation will focus on asthma disparities. Asthma is not distributed
evenly in society and it is commonly believed that those with lower income are more likely to have asthma.
Dr. Diette presented a graph showing asthma prevalence in children and adults below the poverty line is
higher than those above the poverty line. Being poor is a fairly potent issue that affects number of cases
and asthma severity, and the relationship is not incremental. The function of having money and lower
prevalence of asthma is not a consistent function (i.e., having more money does not result in less risk of
asthma), but rather poverty is the issue.

We see asthma disparities among many groups (e.g., sex, age, gender, and geography), and there are
many factors that can coalesce and be mapped. For asthma, factors such as occupation, indoor allergens,
and indoor pollution contribute to asthma disparity.

Environmental exposure can cause health disparities in many ways, including differential exposure,
susceptibility, and coping strategies. Differential exposures begin outside but move indoors to affect
people where they live, study, and work. Two environmental factors that have the greatest influence on
asthma are inhalant allergens and irritants. Dr. Diette presented an NIH-sponsored figure that illustrated
different routes of pollution and irritants in rural and urban environments. For example, indoor cooking

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fires presented sources of asthma inducing pollutants in rural communities, and smoking affected asthma
in urban areas. Health disparities from exposures occur because where people live is not a random
phenomenon. Minorities are more likely to live in an area that fails the EPA standard. A Woodruff et al.
study examined where pregnant women live to find the relationship between race and ethnicity and
location and found that minority, pregnant women were exposed to the worst air. Studies also found that
often indoor air quality, including allergens and air pollution, can be worse that outside. One study on the
distribution of indoor particulate matter (PM) in children's bedrooms found that indoor fine particles
failed an average of 70 percent of outside standards. Additional studies found that African Americans have
the highest levels of exposure to second-hand smoke and suffer the highest codeine levels after PM
exposure. Differences in how people cook is another factor in health disparities. Exposure from biomass
burning cooking methods are linked to adverse health outcomes as is nitrogen dioxide (N02) exposure
from cooking on an unventilated gas stovetop. Three billion people use biomass burning for cooking,
which contributes to asthma. The odds ratio (OR) of cooking with solid fuel and asthma is 1.8, which is
similar to the OR for tobacco and asthma.

Allergens also play a role in health disparities. For example, African-American and Mexican-American
children are at a higher risk of sensitivity to cockroaches and dust. Residential location also plays a large
role in differences in allergen burden. For example, dust mites are a major allergen in New Orleans and
Seattle, cockroaches are a major allergen in Chicago and New York, and mice are a major allergen in
Baltimore. One editorial by D.R. Ownby compared children's sensitivity to mice and cockroaches to an
allergen and found that mice had the largest spread of reaction and therefore were predicted to have the
highest probability of resulting in an acute allergic reaction that requires a hospital visit. A study by Bell et
al. examined the effects of having central air conditioning on exposure to PM and found a 39 percent
reduction in respiratory hospital admission among the 20 percent of people with central air conditioning.
This finding was consistent with less outdoor penetration of PM indoors.

School location also plays a large role in asthma dipartites in children. The air quality surrounding the
school will impact the children, given the amount of time they spend at school. One study in southern
California examined ambient PM pollution and asthma in children and found a correlation between the
risk of asthma and air quality in school. Another study in southern California examined traffic density near
schools and found that locations where African-American and Hispanic children go to school experience
higher traffic density, further supporting disparities of health. Another study by Sheehan et al. examined
dust allergens in urban schools and homes and found that urban schools have higher pollution.

Occupation is another contributor to health disparities. For example, bakers have high rates of asthma
and respiratory conditions due to their professions. Approximately 15 percent of asthma cases are due to
occupation, and occupational lung disease is the number one contributor to work-related illness in the
United States. Different occupations pose different risk and different ethnicities have different
sensitivities. For example, Asian-Americans have the lowest percent risk of lung disease in high risk
occupations and Hispanics are most likely to have high-risk occupations such as painting, carpentry,
working with textiles, or baking.

Where people live, learn, and work affects their risk of asthma, and asthma disparities can be linked to
indoor environment differences. Age, sex and gender, race and ethnicity, and geography groups are

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exposed to different mixtures, resulting in different adverse health outcomes and different disparities in
health.

Dr. Geller thanked Dr. Diette for his presentation and asked the audience to think about how to set
standards to prevent asthma. He then introduced the next speaker, Dr. Rosalind Wright, to present on the
window of opportunity for health improvements during pregnancy due to parents' heavy investment in
life changes.

Psychological Stress & Perinatal Programming of Chronic Disease
Rosalind Wright, M.D., M.P.H. | Icahn School of Medicine at Mount Sinai

Dr. Rosalind Wright explained that she would present on environmental risk and psychological stress,
which is an area that is expanding and is important to the asthma picture as well as health more broadly.
The first principle is that early-life experiences can influence later-life health and disease. In other words,
the stages of life are a continuum, and life experiences and exposures have impacts over time. To
understand disease, such as pulmonary disease, one must take a life-course perspective and see
pregnancy and early childhood as the biggest levers for disease prevention, which is why Dr. Wright is an
adult trained Pulmonary and Critical Care Medicine physician who now sits in a pediatrics department.
Numerous studies have evidenced maternal exposure to air pollution, including particulates, carbon
monoxide, sulfur and nitrogen oxides, ozone, and tobacco smoke, as associated with low birth weight,
congenital defects, fetal and neonatal deaths, decreased lung growth, increased rates of respiratory tract
infections, asthma, behavioral problems, and neurocognitive impairments. These outcomes can also have
further health effects. For example, low birth weight is linked to obesity in teen years and adulthood and
is a risk factor for adult cardiovascular disease, hypertension, and type 2 diabetes. As noted previously,
these diseases in midlife (especially diabetes) are associated with increased risk for the development of
Alzheimer's disease and dementia in later life. Dr. Wright leads a transdisciplinary team of scientists at
Mount Sinai which is conducting a prospective birth cohort study to measure the components that
contribute to asthma risk and other developmental disorders, such as psychological stress, diet, air
pollution, home allergens, and tobacco exposure, in low-income populations to determine the large
drivers and identify areas of intervention. Stress was identified as one of the top contributors and the
study then looked at how it gets into the body to impact health.

The physiological imbedding of stress is similar to inhalation exposure, as physiological disruption can
result from the emotional-cognitive processing and response to an external stressor. Stress activates the
central and peripheral components of the stress system, or the hypothalamic-pituitary-adrenal (HPA) axis
and the arousal/sympathetic system, resulting in changes in levels of stress system principal effectors,
including corticotropin-releasing hormone (CRH), arginine vasopressin, proopiomelanocortin-derived
peptides alpha-melanocyte-stimulating hormone and beta-endorphin, glucocorticoids, and
catecholamines such as norepinephrine and epinephrine. Stress response is normative and part of well-
being, and people need stress to respond to daily challenges. There is an optimal level of stress, however,
that we would like to operate under, and overwhelmed stress and coping mechanisms disrupt key stress

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regulators and can result in impaired growth and development and a number of endocrine, metabolic,
autoimmune and psychiatric disorders.

Asthma is a disorder of immune disruption, so it is reasonable to think that asthma risk is affected by
disruptions in the stress system. There are critical windows during pregnancy and during the first two
years of life when the respiratory system is rapidly developing, and thus these are critical windows where
toxins like stress can alter lung development and structure and result in disorders such as asthma. This is
not dissimilar to the story with tobacco exposure which is another known main driver of asthma risk in
early life.

Evidence suggests maternal stress during pregnancy alters the child's developing immune response. The
Asthma Coalition for Community, Environment, and Social Stress (ACCESS) study used a prospective
pregnancy cohort to quantify exposure to stress during pregnancy and early life to see health effects later
in life and the dose effect of chronicity and severity of experienced stress. The cohort consisted of 955
pregnant women recruited from community health centers in Boston, Massachusetts from 2002 to 2009.
These women had low socioeconomic standings (SES), 65 percent of whom had less than a high school
education. The study used life event measures covering many life domains, including financial strain,
relationship problems, racism discrimination, community violence, domestic violence, and maternal
experiences prior to pregnancy, to quantify maternal cumulative stress. The study found that stress coping
methods were overwhelmed when the mother experienced adverse events across multiple domains and
adverse health outcomes occurred in a dose-response manner (i.e., the higher the stress, the greater
effect on asthma risk in the child). When examining the relationship for prenatal and postnatal maternal
stress and child repeated wheeze by age two to three years, both prenatal and postnatal wheeze showed
a strong linear dose-response relationship to in-utero exposure to maternal stress. When adjusted for
other exposures such as ambient air, tobacco, and diet, there was still a strong independent effect of
stressors on child wheezing. The same study also looked at the relationship of exposure to maternal stress
during pregnancy and up to two years to asthma in children followed up to seven years of age. The study
found that postnatal stress impacted asthma rates in both boys and girls and found a positive increasing
trend for in-utero exposure to maternal stress and asthma particularly in boys. This sex difference in
response alludes to vulnerability of boys and some protection of girls from in-utero exposure to stress.
The study then examined if the level of stress or if a particular period of exposure was driving asthma and
found that chronicity of stress also matters and early life toxic stress that was high in both the prenatal
and postnatal periods was associated with lower levels of lung function by age seven years. This is
concerning as those with reduced lung function by age six to seven years have been found to be at greater
risk for chronic obstructive lung disease and cardiovascular disease in adulthood as well at early mortality.
In other studies done by Wright's group, cumulative prenatal stress in women has also been associated in
a dose-response manner with altered immune function in infants at birth. Children with mothers who
have higher day-to-day Cortisol levels, a biomarker indicative of higher stress, have also been found to be
at higher risk of early respiratory problems.

In other work by Wright's group, stress is identified as a key factor contributing to health disparities.
Studies have shown that African-American women have the highest exposure to traumatic and non-
traumatic stressors over their lifetime and more often suffer from post-traumatic stress disorder (PTSD)

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than women of other ethnicities. African-American women are more likely to report a history of childhood
abuse and have higher levels of hair Cortisol across all three trimesters of pregnancy when compared to
White women. Hispanic women also had significantly higher hair Cortisol levels than White women during
pregnancy but lower levels than African-American women. These differences in in-utero exposures by
ethnicity may result in health disparities in children as well as adults. Providing a better quality of life with
fewer stressors from the beginning of life may have long range benefits throughout the life course. This
is why the prenatal and early childhood periods are potentially the most effective lever for reducing
chronic disease risk.

Students Break the Cycle of Environmental Health Disparities

Leslie Rubin, M.D. | Southeast PEHSIJ at Emory University and Morehouse School of Medicine

Dr. Leslie Rubin remarked that previous presentations have done a great job explaining and providing
evidence to what the health disparities are, and his presentation will focus on strategies to reduce these
disparities and promote health equality, particularly in the Southeast. The Southeast was an area greatly
affected by slavery and the civil war, and therefore it is no accident that it is the region with the greatest
degree of health disparities.

Poverty is a powerful force in health disparity issues, but also includes ethnicity, racial discrimination, drug
and alcohol abuse, access to good health care, exposure to violence, and home insecurity, and children
are the most at risk for these health disparities. The built environment is one factor that is greatly affected
by income and plays a large role in health disparities. Poor communities are often unsafe due to traffic
crime, trash, lack of access to grocery stores, and have limited green space, resulting in increased obesity
among people in these communities, which in turn contributes to an increase in associated diseases such
as diabetes and hypertension that reduce life expectancy and quality of life. Poor communities are also
more likely to be exposed to contaminants such as lead from older homes and schools in poor condition.
People in poor communities are exposed to more indoor and outdoor pollutants and children in those
communities are three times more likely to suffer from and die from asthma. In addition, poor
communities also have less access to education resources making students less likely to graduate and
more likely to be unemployed and go to jail, which is extremely costly. Lower education levels are also
associated with smoking. These cumulative and chronic health disparities are part of a self-perpetuating
cycle involving social and economic, residential, environmental, health, and compounding factors. These
cumulative factors and their consequences contribute to an intergenerational cycle which he termed the
Cycle of Environmental Health Disparities.

A collaborative effort between the Southeast PEHSU and Innovative Solutions for Disadvantage and
Disability (ISDD) a private not-for-profit community organization created a program called Break the Cycle
of Environmental Health Disparities to address these persistent health disparity issues that so dr. The
program invites university students from all disciplines to develop projects that will break the cycle of
environmental health disparities in children at any point. The students are required to have university
faculty mentors and are guided in their projects by the Break the Cycle faculty and in the process are
educated on environmental health and health disparities. At the completion of their projects, the students

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are required to present their project at a national meeting and to write up their project for publication.
Examples of projects from the past Break the Cycle program were: Endocrine Effects and Metal Exposure
in Children of Agricultural Working Mothers in Thailand, Racial and Socioeconomic Status (SES) Profiles in
People Living Near Power Plants, Impact of Housing on Body Size and Pubertal Timing, Environment,
Malnutrition and Teenage Mothers in Lusaka, Zambia, Community Supports Lessen Health Disparities for
Premature Infants, and Home Environment, and Low Income and the Primary Care Medical Home. The
goals of the program are to raise awareness of children's environmental health and environmental health
disparities and to cultivate future leaders to continue to address these disparities far into the future. To
date, Break the Cycle has had ten annual programs; has supported 93 students in 27 university
departments; from nine U.S. states, Latin America, Europe and Africa; and has resulted in eight
international journal supplements and six books. A program survey showed that the program is effective
at increasing knowledge in children's environmental health and disparities and influencing participant's
future career choices. This simple program with simple funding can make a big difference in future health
disparities. The program supports the Southeast PEHSU's goal continue to address health disparities now
and well into the future to reduce environmental health disparities as much as possible.

CalEnviroScreen and Potentially Preventable Childhood Morbidity in California's Central Valley
Emanuel Alcala, M.A. | Central Valley Health Policy Institute

Mr. Emanuel Alcala thanked the meeting organizers for the opportunity to participate in the meeting and
explained that his presentation will be focused on CalEnviroScreen and Potentially Preventable Childhood
Morbidity in Central California. Central California, particularly the San Joaquin Valley, is more rural than
southern California and CalEnviroScreen was California EPA's tool to measure cumulative impacts and
population characteristics of communities identified by the tool as disproportionally burdened by
pollution and exposure. The tool combines a population characteristics score and a pollution burden score
to calculate the screening tool indicator to identify high risk and heavily burdened communities. The
population characteristics score includes age, education, linguistic isolation, poverty, race/ethnicity,
asthma, and low birth weight. The pollution burden score consists of ozone, PM, diesel PM, pesticides,
toxic release inventory, traffic, cleanup sites, groundwater threats, hazardous wastes, impaired water
bodies, and solid waste.

The tool's objectives are to identify poor health outcomes in children and the tool components that are
associated with childhood morbidity. The variables considered included children under 15 years old who
resided in San Joaquin Valley from 2007 to 2012. Independent variables included age, gender,
race/ethnicity, and zip code. The analysis used multilevel modelling that allowed data measurement at
the individual- and zip code-level. The model first identified the variance in Hospitalization for ambulatory
care-sensitive conditions (ACSC) including asthma, respiratory infection, and pneumonia. Then the model
entered the CalEnviroScreen Score and separately entered the pollution burden score and population
characteristics score to find the association between screening score components and ACSC.

Mr. Alcala presented a table describing the hospitalization rates, or cases, by patient demographics in the
San Joaquin Valley. Children from zero to four have the highest hospitalization rate by a 3-fold. African

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Americans have the highest rate of hospitalization from any racial/ethnic group, but due to the small
percentage of the population and clustering effects in zip codes, these associations were not strong. The
San Joaquin Valley population is mainly Mexican-Americans who exhibited a protective factor when
compared to Whites. The tool model building strategy found that events vary by 23 percent between zip
codes and the CalEnviroScreen Score accounted for 23 percent of that variance. There was also a positive
association between the tool score and ACSC with a higher score associated with higher rates of
hospitalization. The next step was to enter the pollution burden score and analysis found that the score
only accounted for one percent of ACSC. However, the poverty rate accounted for 31 percent of ACSC.
When the population characteristic scores were broken out into individual components, four indicators
were highly correlated to ACSC in San Joaquin Valley: poverty, race/ethnicity, linguistic isolation, and
education.

Diesel particulate matter (DPM) was the only pollution burden characteristic that was significantly
associated with ACSC. It accounted for a small but consistent and independent effect on hospitalization
rates. Linguistic isolation, race/ethnicity, and education contributions to ACSC can be explained by
poverty. From these results, one can see that the CalEnviroScreen can identify communities with poor
health outcomes in children, specifically communities with the largest burden for hospitalization. The
components of the CalEnviroScreen tool associated with childhood morbidity are poverty, race/ethnicity,
linguistic isolation, education, and DPM. In addition, including neighborhood poverty eliminates the
impact of individual race/ethnicity on health disparities.

Session 4 Questions, Answers, and Comments

Dr. Geller thanked the speakers for their presentations and invited them up to the podium for a panel
discussion. He mentioned that EPA released the EJScreen tool, which pulls together social and
environmental factors and provides an index that targets high risk communities, similar to the
CalEnviroScreen tool that tells users locations where deeper examination should occur.

Irva Hertz-Picciotto, UC Davis, cautioned against using the term "protective" when discussing results of
health disparities analysis, because one of the factors that could be affecting lower hospitalization in a
particular health disparity group could be that one group is not seeking medical care. This is seen in
families with undocumented members in particular. Mr. Alcala responded that a large population in the
San Joaquin Valley is undocumented and the reason the CalEnviroScreen analysis did not further
investigate this was because they wanted to make a stronger point toward their indices.

Kathleen Alexander, Virginia Polytechnic Institute and State University, asked what the vision is for seeking
behavioral impacts on health and how vulnerability should be examined in that context. Mr. Alcala
responded that ultimately the field needs better measures. He explained that other studies have
examined the Hispanic paradox, or the finding that Hispanics tend to have lower mortality rates in poorer
communities. When these studies adjust for age at death, African Americans are dying prematurely, so
different measures need to be developed to identify the causes of premature death within that group. Dr.
Wright added that population groups can be further broken down to give a more accurate examination
of health disparities. For example, prevalence of morbidity from asthma is lower in Mexican Americas

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than Latinos, but that cannot be observed when Latinos are all grouped together. Dr. Rubin built off the
issue of generalization and noted a publication on the heat crisis in Chicago in the mid-1990s. There was
a higher number of deaths in Cook County than surrounding counties and when that number was further
broken down, there was a higher proportion of average number of deaths in from African Americans than
in Hispanic populations. The higher proportion of deaths could be attributed to African Americans who
were old and lived alone in abandoned neighborhoods. Latinos typically have a rich sense of community.
This attests to the value of social capitol in terms of individual and communal resiliency.

Liam O'Fallon, NIEHS, asked what the public health message to pregnant women is from this discussion.
In particular, knowing the health effects of in-utero exposure to stress, how this research would be
translated in messages for pregnant women without stressing them out. Dr. Wright stated that this
information needs to be delivered by clinicians. Physicians can validate that pregnant women need to
reduce stress, discuss what those stressors are, and make a plan to eliminate those stressors. Additional
approaches to translating this research include pregnancy centers that provide the opportunity for
pregnant women to come together to discuss and share ways to reduce stress and by fixing poverty so
poor women have less stress during pregnancy. Talking to people about the importance of stress and
stress management is the most effective way to address this problem. Dr. Wright added that she has sent
a lot of people to therapy and has seen a great reduction in their medical symptoms as a result. She has
seen patients come off of steroids and other medications and asked meeting participants to think about
different interventions that might work in different communities. She added that she hopes resources
that allow medical practices to be reimbursed for mental health services are provided on a large scale in
the near future.

Kimberley Gray, NIEHS, noted that the earlier session speakers gave great recommendations on where
the scientific community should head. Given all of the scientific evidence about the harmful effects of
stress, diet, DPM, etc., she asked who the target audience for translating this information to is. She asked
if it should be at the maternal or household level and if NIEHS is missing a specific population that this
information can be disseminated to so as to avoid burdening mothers with additional messaging. Dr.
Wright stated that it is easier to create a strong child than it is to repair broken adults. She recommended
that NIEHS focus their efforts in the critical windows of early child development, specifically during
pregnancy and early childhood. Obstetricians need to be educated on prenatal and early childhood
environmental exposures, such as chemical and stress exposures, to address the issue that pregnant
mothers are not thinking about how their exposures affect their child later in life. Dr. Diette explained the
success of the Clean Air Act and noted that it is one of the most important public health regulations in the
United States. The recent reduction in the permitted level of ozone is great, but it is not enough. He
suggested that scientific research align with regulation review requirements so they can be used as
evidence to support regulatory standards. Harmonization is key and Dr. Diette asked meeting participants
to think about how their research could respond to regulator needs and be translated into policy when
conducting future studies. Dr. Rubin agreed and noted that collaboration between agencies should take
place to break the cycle of health disparities, address issues of poverty and race discrimination, and invest
in education of young people. Addressing these issues will also benefit society as a whole and result in a
positive feedback loop. Dr. Wright noted the indirect chemical environment and nutrition program that
has shown the success of educating patients on how stress and diet can offset the toxicity chemical and

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ATnonchemical stressors that can be impacting their health. Similar programs can be done and have
positive health impacts now.

Dr. Geller noted that policy decisions are any opportunity for improving health outside of the clinic. HIAs
include all of the factors that have been discussed and are essential to policy assessments. NIEHS and EPA
should work together to ensure a comprehensive review of all the factors that play a role in a specific
health outcome so that the appropriate considerations are included in the policy decision making process.

Sally Darney, NIEHS, noted the issue of teenage pregnancy prevention and how this issue touches on
interrelationship between poverty and culture. Poor communities are often more accepting of early
pregnancies and large families. Family planning should be accessible and free in these locations and there
is currently a lot of policy discussion surrounding this issue.

David Evans, Columbia University, noted that the scientific community needs to think about developing a
set of guidelines for straightforward and simple messages that can be easily disseminated by physicians.
For example, successful asthma guidelines were developed for messaging to reduce risk of asthma.
Physician practices and outside interest groups can use these guidelines as a standard to apply to their
own materials when looking to advise parents on things to check for in the home and environment.

Jennifer Lowry, Children's Mercy Hospital, noted that effective messaging is what PEHSU is tasked with
doing. PEHSU is focused on creating guidelines for effective messaging and there are a lot of factsheets
on www.pehsu.net that address the messaging issue.

Linda Birnbaum, NIEHS, noted that the opportunity with PEHSUs is larger than was originally realized. She
added that putting things on a website is not adequate communication and asked meeting participants to
think about what is needed by women and children health care providers and the need to think more
broadly than pediatrics.

Session 5 - Lifestage Approach to Prematurity

Moderated by Michael Hatcher, Ph.D. | Chief, Environmental Health Branch, ATSDR, CDC

Dr. Michael Hatcher of the CDC explained that the goal of the Health Resources and Services
Administration (HRSA) is to integrate environmental risk and exposure and to protect the 40 million
people the program serves. He has found that working with the next speaker, Dr. Michael Lu, has been a
great opportunity.

The Life Course Perspective and Children's Environmental Health
Michael Lu, M.D., M.S., M.P.H. | Heath Resources and Services Administration

Dr. Michael Lu explained that his presentation will describe the life course perspective and the
implications for children's environmental health. HRSA's Maternal and Child Health Bureau (MCHB)
envisions an America where all children are healthy and have a fair shot to reach their fullest potential.
Dr. Lu has a staff of 180 and an annual budget of $1.3 billion, about half of which goes to support the Title

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V Maternal and Child Health Services Block Grant which funds the public health system for maternal and
child populations in 59 states and jurisdictions.

The Block Grant also supports special projects of regional and national significance, including the
MotherToBaby network through the Organization of Teratogen Information Specialists; a third of this
support goes to the Maternal, Infant, and Early Childhood Home Visiting Programs and the rest goes to
support a myriad of MCHB programs. MCHB categorical programs include topics such as autism and other
developmental disabilities, traumatic brain injury, sickle cell service demonstration, universal newborn
hearing screening, heritable disorders, emergency medical services for children, Family-to-Family
information centers, and Healthy Start. MCHB runs approximately 100 different programs that touch the
lives of more than 42 million women, children, and families, including half of all pregnant women and one-
third of all infants and children in our nation each year.

The MCHB can be thought of as a platform and partner for improving children's environmental health.
Simply stated, the life course perspective is a way of looking at life not as disconnected stages, but as an
integrated continuum. It is a conceptual framework—or paradigm shift—which recognizes that each stage
of life is influenced by all the stages that precede it, and it in turn influences all the life stages that follow
it.

The life course perspective consists of two components: an early programming component and a
cumulative pathways component. The early programming model posits that experiences and exposures
early in life (i.e., in utero) can influence a child's health and function for life. This is the basis for the Barker
Hypothesis, which is a series of studies that discovered a relationship between low birth weight and
increased risk for coronary heart disease, hypertension, and diabetes later in life. Low birth weight adds
to the risk factors that are typically associated with heart disease, such as smoking, high blood pressure,
high cholesterol, and obesity. Barker and his colleagues hypothesized that there are critical periods in
development during which the functions of an organ or system are being programmed, and if something
goes wrong during fetal programming, then that organ or system may not function optimally over the
entire life course. For example, if malnutrition were to occur for the fetus in the second trimester when
the pancreas and kidney are rapidly developing, the pancreas could be smaller with fewer beta cells
and/or the kidneys could be smaller with fewer nephrons, which would increase the child's susceptibility
for diabetes and/or kidney diseases later on in life.

Over the past two decades, there has been much scientific evidence to support the concept of fetal
programming. Dr. Lu described his research at the University of California, Los Angeles (UCLA) that
examined the effects of maternal stress on the fetus during pregnancy. Maternal brain and body stress
hormones can cross the placenta in various ways: through incomplete inactivation of maternal Cortisol by
11B hydroxysteroid dehydrogenase (HSD), which can be exacerbated by stress or inflammation, or
through activation of placental corticotropin-releasing hormone (CRH), which in turn activates the fetal
HPA axis. In a sense, the baby bathes in these stress hormones, priming the fetal brain for stress and
resulting in prenatal stress.

The hippocampus and amygdala are two areas in the fetal brain that are particularly vulnerable to the
neurotoxic effects of glucocorticoids. Maternal stress results in fetal exposure to high levels of
glucocorticoids (Cortisol in humans and corticosterone in animals) which can downregulate or decrease

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the number of glucocorticoid receptors in the hippocampus and upregulate or increase the number of
glucocorticoid receptors in the amygdala. The hippocampus is responsible for learning and memory
formation. In animal studies, rats exposed to a great deal of prenatal stress have difficulty forming
memories and learning new tasks. The amygdala mediates anxiety and fear, and rats exposed to a great
deal of prenatal stress show increased anxiety and fear in aversive situations.

The hippocampus and the amygdala regulate your hypothalamic-pituitary-adrenal axis, which mediates
your fight or flight response. The hippocampus can bethought of as a brake pedal that halts action of the
HPA axis, and the amygdala can be thought of as an accelerator pedal that stimulates the actions of the
HPA axis. Downregulation of the number of glucocorticoid receptors in the hippocampus reduces the
sensitivity of the brake pedal and upregulation in the amygdala results in an increase in accelerator
sensitivity. This results in a hyper-reactive HPA axis (facilitating the fight or flight response) and is the
mother's way of preparing the fetus for the outside world. In the short run, this hyper-reaction could have
survival advantages, but in the long run it could have some serious health and developmental
consequences. There are 13 studies that link maternal anxiety and stress during pregnancy to increased
risk for attention-deficit/hyperactivity disorder (ADHD), suggesting that stress hormones influence the
hardwiring of the fetal brain with long-term health and developmental consequences.

Epigenetic regulation, or the ability to control gene volume, plays an important role. Gene expression can
be modified by a methyl group (i.e., one carbon and three hydrogen atoms) at the front of a gene.
Generally speaking, methylation turns off gene expression, whereas demethylation turns gene expression
on or up. It is thought that exposure to prenatal stress may control the expression of fetal brain
glucocorticoid receptors by simply methylating or demethylating the DNA. Two genetically identical
individuals may have different levels of stress reactivity based on whether genes are methylated or
demethylated. This attests to the importance of maternal stress in a child's health and development over
a lifetime.

The epigenetics phenomenon has been demonstrated in mice where different phenotypes and eating
behaviors were exhibited by genetically identical mice. Differences in the expression of the agouti gene
can change the animal's fur to blond or cause them to overeat, resulting in a higher risk for obesity,
diabetes, and cancer later in life. The difference in agouti gene expression was the result of different
maternal ingestion levels of folic acid during pregnancy. Folic acid is rich in methyl groups and can
methylate or silence the obesity gene during pregnancy. Epigenetics provides great opportunity for
intervention by controlling gene expression to prevent disease even before a child is born. This may not
be a possibility in the near future, but this study shows how early nutrition can influence DNA methylation
resulting in lifelong, and perhaps intergenerational, impacts on health and function.

The second component of the life course perspective is cumulative pathways, which posits that chronic
biological and psychological stress can cause wear and tear on the body's adaptive system, leading to a
decline in health and function over time. Allostasis, or the body's self-regulating process to maintain
stability, works well for fight or flight stress, but the body can lose its ability to self-regulate in the face of
repeated or chronic stress. The elevated levels of Cortisol during chronic stress start to downregulate the
glucocorticoid receptors in the brain, increasing the circulating levels of stress hormones, and causing
individuals to produce more stress hormones than normal in response to stressful events. These events

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activate a sympathetic response that can lead to increased, chronic, and uncontrolled cardiac output
which, over time, can lead to hypertension and cardiovascular diseases. Stress activates the body's HPA
axis to produce the glucocorticoid (i.e., Cortisol), which mainly functions by converting stored energy into
usable energy (i.e., glucose) through partially impeding insulin action. The HPA axis cannot be shut off
when chronically stressed and excess glucocorticoid over time can lead to glucose intolerance and insulin
resistance. This stressed out state can cause damage to the body as opposed to protecting it. Chronic
stress also reduces the ability of the HPA axis to downregulate the immune system, wearing it out,
depressing the immune function, and increasing the risk of infections and inflammation. Uncontrolled
inflammation results in an increased likelihood of chronic diseases such as hypertension, diabetes, heart
disease, Alzheimer's disease, lupus, nephritis, and all autoimmune diseases. Pregnant women can be more
susceptible to infections like bacterial vaginosis, which can increase their risk for preterm birth.

Lastly, acute stress can increase the growth of neurons inside the hippocampus and prefrontal cortex, the
learning centers of the brain that allows us to learn from mistakes. Under chronic stress, however, neuron
atrophy and death occur in these learning centers causing forgetfulness and memory loss.

A 2007 report from the Institute of Medicine Committee discussed the need to rethink the causes of and
preventative measures to address preterm birth. The cause of preterm birth was previously thought to
originate during pregnancy or at the time of labor but is now thought to be due to maternal exposure,
stress, and infection over her lifetime. This would support the need for more preconception care for
women to stabilize stress.

To improve children's health, further research and investment is needed to understand the types of
exposures that matter the most. The most important influences on children's health (e.g., nutrition, toxic
stress, and environmental exposures) are the things that are least examined in clinical practice. Ob-gyns
and pediatricians must be adequately trained and equipped to deal with these issues. The American
Academy of Pediatrics has been discussing the use of a team-based approach that includes health
educators, social workers, and dieticians to address these issues. Reducing maternal exposures—not only
during pregnancy but throughout her life course—is urgent and critical for ensuring healthy children. A
target for this action should be communities with limited access to this type of information to help ensure
that all children are healthy and have a fair shot in life.

Session 5 Questions, Answers, and Comments

Susan Buchanan, University of Illinois at Chicago, said she was thrilled to see Dr. Lu reaching out to
meeting participants to foster future collaborative efforts. She took the opportunity to advise attendees
that every other month the PEHSUs meet with the MCHB to discuss areas for collaboration. PEHSU is
working with the MCHB as it already recognizes that environmental exposures are critical during
preconception, in-utero, and adolescent stages, and PEHSU consists of the nurses and public health
specialists who work with mothers to educate them on the risks described at this meeting. Susan asked
for concrete actions that the MCHB is going to take to incorporate children's environmental health into
their work and proceeded to answer her question with a recommendation that MCHB fund PEHSUs either
through the Children's Centers or through a program that would train the next generation of public health

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professionals. Dr. Lu responded that the children's health scientific community first needs to determine
what the goals for the state of the science by 2020 so that a national strategy can be developed that
ensures the work is completed and the information reaches everyone who could benefit. He explained
that this should be a collaborative effort between EPA OCHP, CDC, and other stakeholders. He suggested
they come together on a regular basis to form a common vision and strategic plan for reaching 2020 goals.

Edward Levin, Duke University, noted that he would like to avoid environmental contamination that harms
children's health but asked the attendees to not abandon those children already harmed. This effort needs
to include adequate treatment for children that are victims of past exposure. Dr. Lu explained that it is
important to look at this issue from a life course perspective so as to avoid looking at prevention in buckets
or silos but rather as a comprehensive strategy. Looking at exposure as a continuum across all life stages
is what is needed to prevent and treat exposures.

Paul Wax, American College of Medical Toxicology, explained that the American College of Medical
Toxicology has a national program dedicated to health care professionals who work on these issues, but
they can only do so part time due to lack of resources. He noted the opportunity to build upon what has
already been created over the past ten years to help underserved populations gain access to this health
care information.

Session 6 - Neurodevelopmental Disorders

Moderated by Susan Schantz, Ph.D. | University of Illinois at Urbana-Champaign

Lessons Learned From the New Bedford Cohort Study
Susan Korrick, M.D. | Harvard University

Dr. Susan Korrick discussed the results and implications of research in the New Bedford Cohort Study, with
a specific focus on prenatal polychlorinated biphenyl (PCB) exposure and subsequent neurodevelopment
in children. She began her presentation by giving a brief background on PCBs, a family of structurally
related compounds used in a wide range of industries for several decades before being banned in the
United States in the late 1970s. Due to their chemical properties, PCBs accumulate in the environment
and in the human body. Populations continue to be exposed, though at relatively lower levels than in the
past. Also PCB production as an inadvertent by-product of pigment manufacturing, and unrelated to past
legacy industrial use, has been described in recent years. In particular, green, blue, and yellow pigments
can contain non-trivial PCB concentrations and are found in household paints, cosmetics, plastics,
newsprint, magazines and other products. She explained this new source of PCB exposure has a unique
congener profile compared to legacy PCBs and the potential health effects are not yet understood.

Dr. Korrick then gave an overview of the current evidence of the association between PCBs and adverse
childhood neurodevelopment. Prenatal PCB exposure appears to have the most deleterious effects and is
related to memory function in a variety of contexts, including novelty preference, short- and long-term
memory, and working memory. Fetal exposure to PCBs is also associated with negative impacts on
impulsivity and attention, which are deficiencies characteristic of ADHD.

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Next, Dr. Korrick discussed the New Bedford Cohort (NBC) Study, which is comprised of 788 children born
between 1993 and 1998 to mothers living in one of four communities near the New Bedford Harbor, a
PCB-contaminated Superfund site. The aim of the study is to assess the impact of early-life exposures to
a host of suspected neurotoxicants (e.g., metals, organochlorine pesticides, and PCBs) on child
neurodevelopment and growth. Dr. Korrick noted that the mothers in the cohort are majority white with
a large proportion low-income, unmarried, and with low educational achievement (high-school education
or less), which generally reflects the population of New Bedford at the time of study recruitment.

In comparison to nine other child development cohorts considering PCB exposure, the NBC study
population had the lowest cord serum PCB concentrations. Many of these other cohorts had two-to four-
fold higher concentrations than the NBC.

Infants enrolled in the NBC study were assessed using the Neonatal Behavioral Assessment Scale (NBAS),
which tests neonatal reflexes in addition to a battery of behavioral and supplementary items. The NBAS
has been shown to be sensitive to a number of risk factors, including prenatal drug exposures,
prematurity, and PCB exposure. To capture an attention measure in neonates, Dr. Korrick and her research
team identified three NBAS measures of interest: alertness, quality of alertness, and cost of attention (i.e.,
how hard the baby has to work to participate in the exam). Across increasing quartiles of cord serum PCB
levels, these babies scored more poorly on these attention measures even as neonates.

At six months of age, infants were administered the Fagan Test of Infant Intelligence to assess visual
memory and information processing efficiency. The Fagan Test is based on the principle that an infant
should prefer to look at novel stimuli, which presumes the baby remembers something they have already
seen is old. The test has two components. The first is the familiarization trials, where the baby is shown
faces that it must learn. The second component is the novelty trials, where the baby is shown a learned
face and a novel face and the proportion of time the baby spends looking at the novel face is a reflection
of the baby's memory. The Fagan Test has been shown to be predictive of subsequent cognitive function.

Dr. Korrick reported that when overall novelty preference was assessed, they observed no association
with cord serum PCB levels. When the investigators considered only trial one novelty, which is a part of
the Fagan Test and is a classic visual-memory paradigm without bias in the choice of faces or the order of
the trials, they observed substantial decrements in novelty preference associated with increasing cord
serum PCB levels. PCB-associated decrements in frequency of fixation were also observed. Dr. Korrick
underscored the importance of carefully considering outcome measurements in analyses; for example, a
priori identification of specific aspects of the outcome that are most relevant may achieve greater
granularity than is possible with a more standard analytic approach.

Dr. Korrick then explained the behavioral assessments conducted on the children at eight years of age.
The Conners' Rating Scale was given to the child's teacher, who answered the 59 item questionnaire that
rates problem behaviors in children. The four Conners' subscales analyzed were all related to behaviors
characteristic of ADHD. These were the overall Conners' ADHD Index, in addition to three subscales that
are based on clinical diagnostic criteria defined in the Fourth Edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV): DSM-IV inattention, DSM-IV impulsivity-hyperactivity, and the
DSM-IV combined subscale. Dr. Korrick and her research team dichotomized the continuous outcome
scores and considered the PCB-associated risk of having mild to moderately atypical ADHD-related

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behavior according to the Conners' Rating Scale. Across the different Conners' measures related to ADHD,
there was a substantially increased risk of mild to moderate atypical behavior with increasing cord serum
PCB levels. She noted that the association was stronger for the inattention subscales compared to the
hyperactivity subscales, and that much of the increased risk was observed in the highest quartile of cord
serum PCB concentrations. Dr. Korrick indicated that this suggests a potential for a threshold dose
response relationship in the NBC.

To complement the understanding of attention skills, the Neurobehavioral Evaluation System 2 (NES2)
Continuous Performance Test (CPT), was used at age eight years. A CPT is a computer-based test that
measures inattention and impulsivity. For the NES2 CPT, children were shown images of animals at
random intervals and were instructed to press the key only when the image of a cat appeared. The CPT
assesses the child's response time as a measure of attention, the number of errors of omission (e.g., when
the child failed to click when a cat appeared) and the number of errors of commission (e.g., when the child
clicked when an animal other than a cat appeared). The strongest finding of the CPT analysis was an
association of higher cord serum PCBs with greater errors of omission, which is reflective of inattention.
This association was sexually dimorphic; it was observed in boys but not in girls.

Finally, Dr. Korrick discussed the results of the Wechsler Intelligence Scale for Children, Third Edition
(WISC-III), which is an IQtest that the researchers conducted on their participants at age eight. There are
two components of the WISC-III on which children with clinical ADHD often do poorly: processing speed
and freedom from distractibility. Analyses of these two components of the WISC-III also suggested sexual
dimorphism, with PCB-associated decrements in processing speed in boys but not in girls.

Dr. Korrick discussed an analysis that considered whether there were potentially spatially variable risk
factors associated with ADHD in the New Bedford Cohort. She showed a map of predicted Conners' Rating
Scale ADHD scores based on residential address at time of birth. The image indicated hot spots with high
ADHD scores west of the PCB contaminated New Bedford Harbor and cold spots with low ADHD scores in
other areas. When the results were adjusted for socioeconomic indicators, the geographic variability in
Conners' Rating Scale scores disappeared. Dr. Korrick explained that this reinforces the importance of
considering all of the important risk factors, including sociodemographic risk factors, for behavioral
outcomes in additional to chemical risk factors in analyses.

Dr. Korrick reiterated that with systematic consideration of outcome measures, she and her colleagues
were able to see decrements in basic skills that underpin intelligence associated with low-level cord serum
PCB levels in children, including memory, attention, and information processing skills. She also noted that,
when considering attention, these PCB-associated differences could be ascertained as early as infancy.
This is critical in building a cohesive understanding of the impact of prenatal PCB exposures on attention-
related skills in school-aged children as well as understanding the influence of PCBs and other
contaminants as risk factors for clinical ADHD.

The Long-Term, Brain-Based Effects of Prenatal Exposure to Two Environmental
Neurotoxicants

Bradley S. Peterson, M.D. | Children's Hospital Los Angeles

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Dr. Bradley Peterson presented on the effects of prenatal exposure to pesticides and air pollution on the
developing brain. Dr. Peterson discussed the critical importance of neurodevelopmental events that occur
during gestation. In the first half of gestation, neurons multiply rapidly. By mid-gestation, the full
complement of what will become adult nerve cells has been established. These newly formed neurons
must then migrate and form dendrites and axons to connect to other neurons to form synapses. Some of
these processes, such as synapse formation, extend into early postnatal life. Most of these developmental
processes are complete by the age of five. Other processes that refine the neurological "hardware"
established in early life can continue into adulthood. For example, myelination begins around the time of
birth and extends well into adulthood. Neuronal apoptosis also occurs during mid-gestation through the
first few months of life, as early prenatal proliferation achieves nearly 150 percent of the neurons
necessary for typical neurological functioning. He explained that each of these maturational events is
uniquely vulnerable to the timing and type of environmental neurotoxicant to which a developing fetus
might be exposed.

Dr. Peterson discussed the impacts of chlorpyrifos, a pesticide used widely during the 1960s for residential
pest control and agricultural purposes. In the early 2000s, EPA banned the indoor residential use of
chlorpyrifos. However, it continues to be popular choice in the agriculture industry worldwide and
remains in the food supply. Animal models have shown that prenatal chlorpyrifos exposure is directly toxic
to the developing brain and nervous system. He showed images of normal rat neuroepithelium and a
similar tissue sample taken from a rat prenatally exposed to chlorpyrifos. Compared to the control sample,
the chlorpyrifos-exposed sample appears disorganized, with cell boundaries effaced and dark, abnormal
nuclei.

Despite the animal evidence, Dr. Peterson explained there was a lack of direct evidence of chlorpyrifos
toxicity in the developing human brain. The Columbia University Children's Center sought to understand
this relationship by recruiting 720 women 18-35 years of age from minority communities in northern
Manhattan. Chlorpyrifos exposure was ubiquitous in this sample, and was detected in 99 percent of
residential air samples as well as 70 percent of maternal and umbilical cord blood samples. Prenatal
exposure to chlorpyrifos was associated with lower birth weight, poorer mental and motor development
at age three, more ADHD symptoms at age three, and lower IQ scores at age seven.

Dr. Peterson endeavored to understand the biological basis for these neurodevelopmental impacts by
conducting an MRI study of chlorpyrifos-exposed children. Forty children of the original 720 mothers
recruited by the Columbia University Children's Center were enrolled in the MRI study. Children 6-10
years of age were divided into high- and low-exposure groups, represented by the highest tertile of
exposure or the middle and lower tertiles, respectively. Dr. Peterson compared the brain structure (i.e.,
the volume of brain tissue at each point across the surface of the brain) across the two exposure groups.

Dr. Peterson showed a video that represented the samples that he identified in the preliminary sample of
40 children. At each point on the surface of the brain, millimeter by millimeter, the relative volume of
tissue was represented by different colors, with turquoise indicating the two exposure groups did not
have significantly different tissue volumes at that point. Purple indicated a significantly lower volume of
tissue in the high-exposure group compared to the low-exposure group, while yellow and red shading
signified a significantly larger tissue volume in the high-exposure group compared to the low-exposure

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group. The frontal lobe was enlarged on both sides, both on the lateral and medial surfaces of the brain.
When prenatal chlorpyrifos exposures were plotted against brain tissue volume, a linear relationship was
observed in the high-exposure group, which indicates the presence of a dose-response relationship.
Regional enlargements in the parietal and temporal lobes have a linear dose-response relationship with
full scale IQ in the low-exposure group; however, the relationship is eliminated in the high-exposure
group. Dr. Peterson explained that a more formal statistical analysis suggested that the enlargement in
the brain accounted for the observed discrepancies in IQ at 7-9 years of age.

Dr. Peterson stated that the cellular basis for the observed neurodevelopmental impacts are unknown,
but based on animal models, chlorpyrifos is known to be toxic to neurons in the developing brain. Scar
tissue develops around the damaged neurons in response to cell injuries and it is speculated that the
enlargements in human brains likely represent scarring from prenatal exposure.

Next Dr. Peterson discussed the effects on the human brain that are associated with prenatal exposure to
air pollutants, focusing specifically on polycyclic aromatic hydrocarbons (PAHs). PAHs are ubiquitous and
toxic environmental contaminants generated by the incomplete combustion of organic materials.
Significant contributors to PAH concentrations include diesel- and gasoline-powered vehicles, waste
incinerators, and oil- and coal-based heat and electricity generation. PAHs have the ability to cross the
placenta and, based on animal models, are known neurotoxicants to the developing fetal brain.

Dr. Peterson explained that a second MRI study, considering third trimester PAH concentration as the
exposure of interest, was conducted on a different sample of 40 children 7-9 years of age from the
Columbia University Children's Center. Dr. Peterson displayed an image of an MRI scan, where purple
indicated an inverse correlation between PAH concentration and brain tissue volume, red or yellow
signified a positive correlation between PAH concentration and brain tissue volume, and green
represented no significant correlation. He explained that a high number of inverse correlations were
observed in the left hemisphere of the brain, but a similar effect was not observed on the right
hemisphere. When associations with the underlying white matter were assessed, the magnitude and
spatial extension of the effect were much larger on the left side of the brain. Dr. Peterson suggested this
shows the abnormality in the surface of the brain is not coming from the grey matter, which is where the
synapses are located, but from the underlying white matter. White matter contains the axons that connect
one region of the brain to another, and it is this wiring of the brain that appears to be most disturbed.
Importantly, in the same regions in the left hemisphere, a reduction in tissue volume is significantly
associated with ADHD, aggression, and rule-breaking symptoms. Furthermore, in the right hemisphere,
an increase in tissue volume is associated with slowing of cognitive processing speeds.

Dr. Peterson noted that similar associations were observed with postnatal PAH exposures through the age
of five, even after adjustment for prenatal exposures.

These ADHD-related findings at the surface of the brain associated with reduced white matter are very
different than wild-type ADHD findings. His research team's initial paper reported bilaterally symmetric
volume reductions in brain matter, not white matter, in the frontal and temporal lobes associated with
wild-type ADHD. PAH exposure seems to produce a specific morphological subtype of ADHD. Why would
PAH affect the brain in such an asymmetric way? We know enough about the molecular processes that
control asymmetry in neurological development, with the left and right sides of the brain different in

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structure and function. It has been suggested that PAHs cause effects through these complicated
molecular pathways that control prenatal development.

Dr. Peterson noted that prenatal and early postnatal life is a time when all the major architecture of the
brain is established and the brain is, therefore, particularly sensitive and vulnerable to the effects of
environmental insults. He reiterated that in the Columbia University Children's Center subsample,
prenatal chlorpyrifos exposure produced bilaterally symmetric increases in tissue volume at the brain's
surface, which is likely a consequence of tissue scarring. The increase in tissue abnormality accounted for
the intellectual deficits associated with exposure. Finally, prenatal PAH exposure disrupted proper growth
of white matter in the left hemisphere of the brain, which is associated with symptoms of ADHD,
aggression, rule-breaking behavior, and cognitive slowing.

It's about 4 Million Brains a Year - Toxic Chemicals and the In Utero Environment
Tracey Woodruff, Ph.D., M.P.H. | University of California, San Francisco

Dr. Tracey Woodruff presented on the effect of in utero exposures to toxic chemicals on
neurodevelopment. She opened by stating that about every one in six American children has a
neurodevelopmental condition and that neurotoxins, such as lead, mercury, PCBs, pesticides, flame
retardants, air pollutants, and arsenic, are detected in more than 90 percent of American pregnant
women. Dr. Woodruff pointed out that only a small fraction of the nearly 8,000 high-use chemicals have
been subjected to thorough toxicity testing and there are potentially other neurotoxic chemicals that have
not been identified.

Dr. Woodruff noted that scientists are currently challenged with working through the existing evidence to
determine potential health effects. She explained a method that she and her colleagues used to advance
the current understanding of the scientific evidence surrounding the effects of polybrominated diphenyl
ethers (PBDEs). The project applies an evidence-based systematic review approach to evaluating scientific
evidence in a way that reduces the amount of bias and produces a clear summary of the state of the
science. She did not go into detail on the specific steps of the approach, but underscored that the method
is guided by an a priori protocol and the steps are systematic, transparent, and thorough. In terms of the
assessment of PBDEs and IQ, she and her colleagues used this approach to identify 12 studies. Specifically,
they considered fetal exposure to BDE 47, a marker for PDBE exposure, and full scale IQ among children
between 5-7 years of age. Each of the individual studies indicated that an increase in PDBE exposure
during pregnancy was associated with lower IQ in children, but the confidence intervals all crossed the
null. Alternatively, the results of the meta-analysis, which increases the power of the analysis, indicated a
statistically significant adverse effect on childhood IQ. These investigators also assessed the relationship
between childhood exposures to PBDEs and childhood IQ and identified essentially the same findings.

As part of the systematic review process, Dr. Woodruff and her colleagues also evaluated the quality of
the evidence. The risk of bias of the internal and external validity were evaluated based on criteria used
in clinical medicine and originally derived from the Bradford-Hill criteria. Based on these elements, the
team found the overall evidence quality for the relationship between PDBE exposure and IQ to be
moderate.

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Dr. Woodruff also discussed the team's counterfactual approach to evaluating strength of the relationship
between PDBEs and IQ. The counterfactual approach explores the magnitude of an effect estimate that it
would it take to drive the meta-analysis result to a null association. They determined that to nullify the
results of the existing studies, a study would need to find that PDBEs improve IQ by a factor of eight. She
noted the size and direction of the counterfactual assessment gave indicates that there is sufficient
evidence of the toxicity of developmental exposures to PBDEs on IQ.

To summarize, Dr. Woodruff presented the results of a completed assessment considering narrative
reviews of perfluorooctanoic acid (PFOA) and birth weight conducted using the Navigation Guide. The
Navigation Guide determines whether the individual reviews conducted high-quality analyses of the
scientific evidence by evaluating the following eight elements:

1.	Is there a clear study question?

2.	Are the inclusion/exclusion criteria indicated?

3.	Is the literature search reproducible?

4.	Was the quality of included studies evaluated?

5.	Did authors analyze data?

6.	Is there a summary findings table?

7.	Was the quality of evidence assessed?

8.	Were the evidence streams integrated?

A high-quality review incorporates all of the elements above. Dr. Woodruff noted that most of the
narrative reviews of the association between PFOA and birthweight indicated the study question, but
almost never gave any of the other information required to have confidence in the evaluation of the
association.

Dr. Woodruff pointed out that PBDEs resemble thyroid hormone structurally. She wondered whether
scientist might have been able to predict the association to avoid fetal and childhood exposures, adverse
neurodevelopmental outcomes, and studies required to assess the relationship. She explained that her
goal is to move the decision-making process upstream by using early evidence.

Dr. Woodruff reminded attendees that they have the ability to influence science policy. She discussed the
Healthy Babies, Bright Futures alliance, which aims to reduce toxic exposures during the first 1,000 days
of development. The three elements of Healthy Babies, Bright Futures are translating science into action,
a focus on cities, and integrated campaigns. As an example of a successful integrated campaign, Dr.
Woodruff noted the group's work to get the furniture industry to remove toxic flame retardants from
their products. The goal of the alliance is to ensure that children have the developmental and intellectual
capabilities to prosper and participate in their communities.

Dr. Woodruff closed by admitting that the road to fully avoiding adverse impacts of industrial chemicals
in children is a long one, but new approaches to evaluating the scientific literature and increased activism
from the scientific community are critical.

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From Science to Policy: Targeting Environment and Neuro-Developmental Risks (Project
TENDR)

llirva Hertz-Picciotto, Ph.D., M.A., M.P.H. | University of California, Davis

Dr. Irva Hertz-Picciotto presented on her work in the science-to-policy arena and the Targeting
Environmental and Neurodevelopmental Risks (TENDR) project. A sizable and growing scientific literature
links a host of environmental chemicals to learning, developmental, and behavioral problems and
disabilities. In fact, autism, attention deficits, and hyperactivity disorders rates of diagnoses have been
rising steadily for the past 25 years. She noted that only a fraction of the increase in autism can be
explained by changes in criteria or diagnostic practice, although the data are still unclear in the case of
ADHD. Given the rising rates and the wide array of chemical connections described in the peer-reviewed
literature, it is time to consider taking action to reduce these chemical exposures.

The mission of Project TENDR is to reduce the exposure levels of environmental chemicals or pollutants
that contribute to risks for neurodevelopmental disorders as a means to lowering incidence of these
conditions. Dr. Hertz-Picciotto explained that children are born with approximately 100 billion neurons
and the proliferation of neurons and synapses occurs rapidly. The prenatal period is therefore a critical
window in terms of neurodevelopment. Project TENDR explores the following neurodevelopmental
disorders: Autism Spectrum Disorder (ASD), intellectual disability, attention deficits, hyperactivity and
other deviant behaviors, learning disabilities, and other neuro-developmental conditions.

Project TENDR brings together environmental health researchers, particularly those investigating
children's environmental health, representatives from a number of societies of clinical health
professionals, environmental health policy makers, and leaders of environmental and child health
advocacy organizations. Initially, TENDR set several objectives: 1) to develop a consensus statement that
would reflect the need to link scientific evidence to actions to reduce exposures; 2) to identify a specific
group of chemicals for which there is a substantial body of evidence of environmental harm, highly
prevalent exposures, and feasibility to intervene to reduce exposures; 3) to create specific
recommendations to reduce exposure to those particular chemicals and prepare a dissemination and
implementation plan.

Dr. Hertz-Picciotto and her Project TENDR co-chair, Maureen Swanson, created an Organizing Committee
that met for the first time in October 2014. The Organizing Committee developed a list of candidate
chemical groups based on the scientific literature. The original list contained over a dozen classes of
chemicals, but faced with limited resources, the group needed to reduce the number of chemical classes
to set feasible goals for moving the science to action.

To hone in on a smaller set of chemical/pollutant classes, the science team prepared summaries of the
epidemiologic evidence and provided links to toxicological data. The considerations for selecting the
environmental factors included the strength of the scientific evidence, prevalence of exposure in women
and young children, and feasibility of intervention. To further narrow the focus, TENDR undertook an
expert elicitation process, which is a formal, structured approach in which experts are systematically
consulted on specific issues where decisions are needed despite incomplete data, uncertainty in the
available information, stakeholders with differing values, and potential choices with various trade-offs.

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The expert opinions were then discussed at a workshop that brought together scientists, policy makers,
and advocacy organizations from numerous entities, including NIEHS, EPA, the National Institute of
Neurologic Disease and Stroke (NINDS), California EPA, American Academy of Pediatrics, Physicians for
Social Responsibility, American College of Obstetricians and Gynecologists, National Medical Association,
National Council of Asian-Pacific Islander Physicians, Alliance of Nurses for Healthy Environments, Alaska
Community Action on Toxics, Autism Science Foundation (ASF), Collaborative on Health and the
Environment (CHE), Children's Environmental Health Network (CEHN), Environmental Defense Fund
(EDF), Learning Disabilities Association (LDA), Natural Resources Defense Council (NRDC), Pesticide Action
Network of North America (PANNA), and The Endocrine Disruptors Exchange (TEDex). The workshop
participants achieved a consensus on "examples of public health failures," or the set of chemicals on which
TENDR will focus its recommendations for exposure reduction, which are:

•	air pollutants (fine and coarse particles, other criteria pollutants, and toxic air contaminants);

•	organophosphate pesticides;

•	PBDEs;

•	lead (due to continuing disparities); and

•	phthalates (considered to have less compelling evidence for neurodevelopmental disorders in
humans, but which represents an example of the hundreds or more chemicals for which human
evidence has yet to accrue, or studies have yet to be conducted.

The workshop participants also formed working groups for each of the chemical/pollutant exposures
selected; these working groups were tasked with drafting the recommendations for exposure reduction.
Working groups were also formed for finalizing the consensus statement, outreach to scientific and health
professional associations for endorsements, public messaging and social media, and scientific
publications.

Dr. Hertz-Picciotto commented that a second workshop will take place in 2016, when the group will refine
the chemical-specific recommendations. The workshop participants will also consider overarching
recommendations, such as the systematic monitoring of a wide range of environmental chemicals with a
specific focus on women and children as well as the establishment of an authoritative body to perform
regular, systematic review of chemicals with potential neurodevelopmental toxicity. Other goals of the
2016 workshop include evaluating the outreach to professional organizations, developing dissemination
plans, considering implementation options, and other aspects of strategic planning.

Session 6 Questions, Answers, and Comments

A participant asked Dr. Woodruff whether the Navigation Guide considers animal evidence or only
epidemiologic evidence. Dr. Woodruff answered that the Navigation Guide is built for both animal and
epidemiologic evidence and noted that for the PFOA assessment, the investigators chose to focus on the
human data.

Darryl Hood, Ohio State University, commented that the group he is affiliated with described the same
brain tissue volume decreases that Dr. Petersen described in a cohort of children from a specific zip code.
He said he is pleased to see that Dr. Petersen is working to uncover associations with environmental

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pollutants such as PAHs. He noted, however, that the asymmetry observed in Dr. Petersen's cohort is not
apparent in the animal models, and thatthis is somethingthat should be investigated further. Dr. Petersen
clarified that no animal studies have considered the axons and white matter, specifically, and have only
looked at grey matter. He added that normally animal models guide the direction of human studies. In
this instance, however, the human investigations must guide the animal models to uncover the specific
cellular elements that are damaged and to identify the molecular mediators of the damage.

Susan Schantz, University of Illinois at Urbana-Champaign, asked Dr. Petersen to comment on the
potential molecular mechanisms of the left-hemisphere effects. Dr. Petersen replied by saying that it
might be attributable to a threshold effect and that perhaps there are sub-threshold effects occurring in
the right hemisphere, but the left-hemisphere effects are more significant. In terms of the molecular
mechanism, he said that there are very specific pathways that control left-right symmetry and he thinks
that these pathways are involved. He explained another possibility is the asymmetric expression of other
molecular drivers and growth factors, specifically neurotransmitters such as serotonin, which are critical
in fetal brain development. Third, there are important genetic controllers of development that are also
asymmetric. He added that it could also be due to a direct effect on myelin.

A participant commented that breastmilk contains many toxic chemicals and asked whether the influence
of exposures in breastmilk are also being studied to ensure the recommendation to breastfeed is a healthy
one. Dr. Hertz-Picciotto replied by noting that in terms of PCBs specifically, postnatal exposure via
breastmilk is, in fact, an order or magnitude higher than the dose delivered prenatally. However, the
association with neurotoxic effects is extremely weak and potentially non-existent. She also reminded the
attendees that breastmilk has undeniable health benefits, such as providing immune factors that aid in
the detoxification of chemical exposures, and at this point there is no evidence indicating breastfeeding
should not be recommended. Dr. Birnbaum added that is important to not stigmatize any young mothers
who may not be able to breastfeed due to in utero chemical exposures that have impacted mammary
development. Dr. Birnbaum mentioned a study out of the Netherlands that explored neurodevelopment
in children of mothers who had elevated levels of PCBs and dioxins. Compared to the children who were
not breastfed, the children who were breastfed had better neurodevelopmental outcomes. Despite both
in utero and early life exposures to PCBs and dioxins, breastfeeding still had benefits.

Kimberly Gray, NIEHS, asked the whole panel if there are new tools to early-life health implications. Dr.
Peterson commented that the next generation of his investigation includes rapid imaging of newborns'
brains to determine whether it can predict their future neurodevelopmental outcomes. Dr. Korrick added
that developing new early-indicator measures and determining how to use existing tests at earlier ages is
important. Dr. Gray followed by commenting that the new National Institutes of Health (NIH)
Environmental Influences on Child Health Outcomes (ECHO) study will include 30,00 kids and aims to
image 10,000 children at nine years of age for addictive behaviors. She asked if there is something to give
the researchers, who will be looking at environmental exposures very broadly, some specific tools to
analyze the data that will be collected to target the environmental toxicant influence on
neurodevelopmental and behavioral health. Dr. Woodruff noted that tools to detect early influences are
important, but they are also controversial in that there is not always consensus around which tool is best

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or whether they are better than tools used a bit later in life. Dr. Hertz-Picciotto advocated for the use of
blood biomarkers.

A participant reiterated the importance of integrating the human and animal evidence. In addition to
mechanistic work, animal studies provide the opportunity to study potential lifespan impacts over the
course of a few years and allow researchers to look ahead.

Session 7a - Obesity

Moderated by Dana Dolinoy, Ph.D. | University of Michigan

i _ _ tribution of Efiwiioiiiiiciiicii t*|jo»uica 10 i-iiiujiioou wocaiif
Rob McConnell, IVi.D. | University of Southern California

Dr. Rob McConnell presented results from the Southern California Children's Health Study. He also
discussed other influential epidemiological studies and the biological plausibility of the relationship
between air pollution and obesity. There is very robust evidence that in utero exposure to maternal
smoking is a cause of subsequent childhood obesity, and animal studies investigating the influence of
nicotine demonstrate the mechanisms. Dr. McConnell suggested some alternative causes for the effects
of in utero and secondhand smoking. Multiple cohorts were selected to represent the different mixtures
and extremes of air pollutants in Southern California, part of a 23-year investigation. He showed images
of two examples of mixtures in which they are interested. The first is the regional pollutant mixture that
blankets an entire community and includes federally regulated pollutants (ozone, nitrogen oxides (NOx),
etc.). The second is the much less studied mixture of pollutants that is emitted from the tailpipe of a car
that exposes communities near traffic corridors [known as near-roadway air pollution (NRAP)]. A number
of different outcomes have been looked at in the Children's Health study. Dr. McConnell focused on
obesity and Body Mass Index (BMI) trajectory in cohorts that range from age five to high school age,
although they are also extending exposure back to birth as part of the Southern California Children's
Environmental Health Center. They have modeled NRAP exposure in many ways, based on traffic
proximity and density, and estimates from land-use regression and dispersion models of N02 and NOx.

Dr. McConnell said there are a number of cross-sectional studies that have examined the association
between NRAP and obesity or increased BMI trajectory. Rather remarkably for a new area of study, there
are three high-quality prospective cohort studies. In 2010, his team published a paper investigating the
association between BMI and traffic density as a built environment variable. Their hypothesis was that
children in a high-density traffic area would not be sent outside to play as much, and therefore would get
less exercise and weigh more. Traffic density within 150 meters accounted for a 0.2-0.3 BMI unit
difference and was relatively specific to a narrow buffer around the home. When physical activity was
included in the model as a mediator, the effect of traffic on BMI did not go away as expected. It occurred
to the team that an alternative explanation for this could be the effect of air pollution. In 2012, a second
paper from the Columbia Children's Center came out investigating the association between BMI and
prenatal polyaromatic hydrocarbon (PAH) exposure. Personal measurements of maternal PAH exposure

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were made. At ages five and seven, there was a significant dose-response relationship for BMI z-score
across tertiles of PAH exposure. A third prospective study, published in 2014, followed a cohort from ages
5-6 to 10-11 years. Dr. McConnell shared a plot of predicted BMI comparing children in different
percentiles of NOx distribution showing residential exposure accounted for approximately a BMI unit in
difference.

McConnell et al. revisited the first 2010 cohort and focused on the relationship between BMI and air
pollution, not just traffic density. Using dispersion model estimates, they found an interesting and
statistically strong interaction with NRAP and secondhand smoke exposure. For individuals only exposed
to secondhand smoke, or only exposed to NRAP, there was an increase in one BMI unit by age 18. For
individuals exposed to both secondhand smoke and a high NRAP there was a combined effect of three
BMI units; this accounts for about ten percent of the body weight of a large man. If these effects are
causal, there are potentially large public health implications. One interesting point is that in this
interaction between secondhand smoke and NRAP, there is no nicotine in NRAP. This indicates that
perhaps there are some complementary or overlapping pathways that account for the secondhand smoke
exposure effects, and that other things in cigarettes could be accounting for these epidemiological
observations. The cause of these effects is still very much an open question, as NRAP composition is a
complex mixture of fresh particle and gaseous combustion products, debris from tires and brake wear,
and metals from engine wear, all of which have inflammatory and oxidant properties.

Dr. McConnell mentioned a few toxicological studies that have been done, including three papers
conducted by a group at Duke that used diesel exhaust particulate as a model NRAP in mice studies. They
dosed mice during gestation and found that prenatal diesel exhaust exposure resulted in increased weight
in males in early life and primed female adults for weight gain on a high-fat diet. The team was interested
in the effects on the central nervous system, and speculated that the mechanism might be through the
damage diesel exhaust did to either feeding centers in the hypothalamus or to anxiety-associated eating.
After reviewing the literature, McConnell et al. compiled a number of other potential mechanisms related
to changes in basal metabolism, such as inhibition of catecholamine-induced lipolysis by PAHs,
mitochondrial damage from early life urban particle exposure, reduced methylation and increased
expression of PPARy induced by early life particle exposure, estrogenic effects of urban particles, and
increased visceral adipose tissue and adipose tissue inflammation resulting from in utero PM exposure.
Dr. McConnell finished his talk by discussing potential practices for clinicians and public health officials to
use to reduce harm from air pollution. There is no substitute for good public policy to reduce ambient
levels of air pollution, unlike other outcomes where behavioral factors have a bigger role. For example,
annual average PM2.5 levels declined from 54 to 13 percent after regulation. Avoiding air pollution when
engaging in outdoor activity is a good recommendation for patients; however, it is important to be
cautious in crafting this public health message to avoid giving people the excuse they are looking for not
to exercise and creating unintended negative consequences. Other options include chemoprevention and
modulation through antioxidants and initiatives to put filters in schools next to major roadways. Initial
data shows these filters can reduce exposure, but additional research is needed.

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Early Toxicant Exposures and Development of Child Obesity: Evidence and Gaps from Recent
Research

Karen Peterson, Sc.D. | University of Michigan

Recent data in children demonstrate that overall rates of obesity differ by gender and region worldwide.
This trend could reflect behavioral, genetic, cultural, or economic differences and is generally referred to
as worldwide nutrition transition. Very broadly, it has been attributed to changes in health behaviors and
environments, such as low levels of physical activity, increased screen time, and high intake of added fats
and refined carbohydrates. These factors lead to obesity and noncommunicable chronic diseases. The risk
factors for obesity are more prevalent in low SES households, especially in urban areas, and include low
physical activity, poor dietary quality, educational attainment, and environmental toxicant exposures. In
2002, a published paper suggested a relationship between toxic exposures and obesity. Although based
primarily on ecological evidence, it also pointed to nonmonotonic low levels where increases in childhood
obesity could be observed.

Dr. Karen Peterson explained that "obesogens" describe a class of chemicals that are considered
endocrine disruptors, to which exposure during development can disrupt metabolic programming, leading
to later obesity. They can disrupt metabolic programming both directly (e.g., increasing number of
adipocytes and stored triglycerides) and indirectly (e.g., basal metabolic rate, shift energy balance to favor
energy storage, alter appetite and satiety). She showed a figure highlighting sensitive developmental
periods when both nutritional and toxicological exposures have a more prominent effect due to epigenetic
plasticity (Figure 1). Generally, in utero and the prenatal period are considered to be the most important,
but many researchers are starting to also look at adolescence and the pubertal transition. These sensitive
periods also correspond with critical periods for obesity development. A growth chart depicted age and a
classic BMI curve, with high levels in infancy and then lower levels between ages four to six years. If
children enter this age period early in life, they tend to have higher rates of obesity later in life. The other
critical obesity period is the peripubertal. There have been a few high profile papers relating some
endocrine disrupting chemicals (EDCs) cross-sectionally to a higher prevalence of obesity in adolescence,
but there might be more to the story. Studies using animal models, such as the twin agouti mouse sisters,
can show life course impacts that differ by toxicant, offspring sex, and period of development. In contrast
to the cross-sectional studies relating bisphenol A (BPA) to obesity in adolescence, the agouti mouse
model shows that BPA exposure in the perinatal period is associated with a lean, hyperactive phenotype,
and lower body weight and body fat in females, with no effect in males. Faulk et al. showed that lead,
usually associated with growth deficits later in life, is related to higher weights across the entire lifespan
of the male agouti mouse model.

A recent review conducted at the University of Michigan took a life-course perspective, and included
studies that were prospective, longitudinal, birth cohorts, primarily containing information on in utero
and early infancy exposures to certain classes of chemicals. A total of 35 post-2011 studies were assessed
in detail for how certain toxicants (22 studies regarding PCBs, DDE/T, PFCs, PDBE, BPA, and phthalates,
and 13 regarding heavy metals) might be related to childhood obesity outcomes (e.g., weight gain, BMI,
percent body fat). First Dr. Peterson talked about the results related to persistent organic pollutants
(POPs), which despite being banned still tend to bioaccumulate, especially in tissues of special importance

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(e.g., breast milk, cord blood, placenta). For prenatal exposure to PCBs, five out of nine studies found no
association with weight gain or BMI in infants or school aged children, but three out of nine showed
increased waist and BMI only in girls at ages five to seven years. For postnatal PCB exposure, decreased
weight from birth to 24 months was found in seven pooled European cohorts. The most clear evidence
overall is for DDT and DDE. Previous reviews highlighted the association between early exposure and the
development of childhood obesity; eight out of 12 studies confirmed this association, across life stages.
DDE has been associated with rapid growth from birth to six months, as well as overweight infants at 14
months, and BMI change to overweight in girls ages five to seven years. Second trimester serum
concentrations of DDT was found to be related to increased waist in nine-year-old boys.

Turning to short-lived but ubiquitous pollutants, the six to eight studies that have been published since
2011 produced mixed, imperfect, and inconsistent evidence regarding the effects of BPA and phthalates.
A Spanish cohort study showed a weak association between BPA and waist circumference at four years of
age. The CHAMACOS study found an inverse relationship between BMI, percent body fat, and obesity of
girls at nine years of age. Finally, increases in leptin in boys and adiponectin in girls at nine years of age
were also found, which contributes to the need for more studies looking at adiposity. For phthalates,
there are surprisingly few studies, but this is the first class of pollutants where the primary effects appear
to be seen in boys. Cord blood MEOHP was related to lower BMI in infant boys. High molecular weight
phthalates were associated with decreased weight gain in infants and lower BMI in boys agesfourto seven
years. An inverse association between BMI, percent body fat, and waist was found in New York City boys
ages five to seven years.

A paper by Afeiche et al. found no effect of lead in males, and an effect on weight of females from birth
to five years of age. Other papers found this effect persisted and was associated with a decrease in BMI
as the girls went through puberty. Other papers related prenatal, but not postnatal, lead exposures to
decreases in weight in infancy or lower BMI in school age girls. Cadmium, arsenic, and mercury were all
found to be negatively associated with weight gains. In summary, for longitudinal prospective studies,
there is the clearest evidence for DDE, primarily in girls. For BPA and phthalates, it is a mixed picture, with
variations by age and gender, and for heavy metals it is decreased weight. Limitations include modest
sample sizes, indirect measures of adiposity or fat distribution, few follow-ups into puberty or adulthood,
and lack of repeat measures of maturational tempo to disentangle effects in boys and girls during the
pubertal transition. Effect modifiers such as child sex; birth weight; maternal weight status; and maternal
dietary intake of fat, vitamins, and minerals also should be considered moving forward.

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Figure 1

Sensitive developmental periods and environmental exposures (Barouki R et al, Env Health 2012)

Genetics

Epigenetic modifiers Epigenetic modifiers
at early development during postnatal life

In utero Chikjhood 4

Adolescence } Adulthood/Senescence

Neonatal

Puberty

Figure 1 Periods of vulnerability to environmental influences. The most critical period is the perinatal period, during which epigenetic
plasticity is high and can be influenced by a variety of environmental cues, including chemicals, nutrition, infection, ere). Later in life, growth and
the hormonally active puberty period is also a vulnerability period. In adults it is believed that elder persons are more vulnerable to a variety of
insults.

Environmental Health and Childhood Obesity: From Research to Action

Maida Galvez, M.D., M.P.H. | Mount Sinai Hospital

Dr. Maida Galvez began by highlighting how the work of the Children's Centers has deepened the
understanding of what is seen in a clinical setting. She showed an infographic from the American Public
Health Association (APHA) entitled "Public health takes on obesity: A route to better health" that
describes the growing problem of obesity in America. Obesity has nearly tripled among children and teens
over the past 30 years. One in three U.S. children ages two to 19 years is overweight or obese, and the
current obesity rate of 35 percent is more than double the rate in 1980. There are 112,000 obesity-related
deaths each year, and obese children are more than twice as likely to die before age 55 as children with a
health weight. This might be the first generation to have a lower life span than the preceding generation.
The direct cost of obesity from medical care expenses is $152 billion per year. The indirect cost, from lost
productivity, insurance premium compensation, and absence from work, is estimated at $73 billion per
year.

The emerging research in children's environmental health has pushed beyond individual risk factors to
consider the broader context of the child. The ecological systems theory, specific to childhood obesity,
examines the child's setting with regard to parenting styles, family characteristics, and the broader
community, demographic, and societal characteristics. School lunch programs, work hours, and access to
health-promoting resources are examples that can have an effect. One of the top drivers of the obesity
epidemic is child poverty which magnifies risk of exposure to environmental hazards. Dr. Galvez showed
an infographic from the American Academy of Pediatrics demonstrating poverty rates by state, including
20 percent in New York, 37 percent in Washington D.C., 56 percent in Puerto Rico, and 42 percent in East
Harlem. Another major driver of obesity is educational attainment. Approximately 143,000 students in

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New York City are in failing schools, and concerns exist about neighborhood safety and crime. The leading
cause of death due to injury in New York City youth ages five to 14 years is motor vehicle crashes, and for
youth ages 15 to 19 years it is firearm injury. Risk factors for firearm injury include being from the Bronx,
African American, and from a high-poverty neighborhood, which also keep children indoors and limit their
physical activity.

Dr. Galvez then discussed how New York City's Environment and Health Data Portal is a superb, user-
friendly tool for exploring New York City environmental and health data. She provided the example of
traffic density in East Harlem compared to Manhattan and New York City. For all vehicle types, East Harlem
had more than double the amount of estimated millions of annual vehicle miles traveled, which is an
indicator of emissions from automobile exhaust, brake wear, and tire wear. As the relationship between
air pollution and childhood obesity is explored in more depth, this has important health implications.

Besides staying indoors and limiting their physical activity, poor children are also living in substandard
housing. In New York City, nearly a third of public housing tenants reported water leaks. East Harlem has
the highest density of public housing in New York City and is ranked number one in average number of
housing concerns for Manhattan. African Americans are the most likely to live in poorly maintained
housing. Approximately 34 percent of black households reported three or more serious maintenance
deficiencies in rent-regulated apartments, compared to 16 percent of white households. Teitelbaum et al.
2012 found an association between phthalate concentration and body size measures in overweight
Hispanic and black children ages six to eight years, specifically in overweight girls.

Dr. Galvez then discussed her research regarding the built environment in East Harlem, which examines
whether there are physical features unique to an inner-city, minority community that impact dietary
quality, physical activity and risk for childhood obesity. Childhood obesity is an epidemic in East Harlem
with 40 percent of girls and 53 percent of boys were at risk or obese. There were striking disparities in
access to healthy foods. In 2004 there were no grocery stores in predominantly African American blocks,
compared to racially mixed or predominantly Latino blocks. Children living on a block with one or more
convenience stores were more likely to have a BMI percentile in the top tertile. When researchers asked
where children in New York City were making their food purchases, the top three answers were
convenience stores, food stands, and fast food restaurants. One study showed that in the toxic food
environment, the dose makes the poison. The more food stores a child passes on their way from school,
the more likely they are to stop and purchase something. This has an associated impact on dietary quality
of increased calories, servings of sugar-sweetened beverages, and servings of snacks and sweets. The
children in Dr. Galvez's cohort also had low physical activity, averaging approximately two hours outdoors
per week with zero hours of structured physical activity. The researchers then looked at the availability of
physical activity resources and found that the more resources children had available (e.g., afterschool
programs and playgrounds), the greater their level of unscheduled physical activity. Families with income
less than $25,000 and with lower caregiver education, however, were more likely to have no resources
on their block.

Despite these figures, Dr. Galvez discussed how there is hope in this issue. Obesity rates have declined for
the first time in recent years, but not in all racial and ethnic groups. Public health improves food choices
and creates opportunities for physical activity, helping to curb obesity. Great efforts have been made to

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bring together diverse stakeholders to think about health policy frameworks, and how we can all work
together to design health communities. One of Dr. Galvez's colleagues is being awarded this week by the
APHA for her work with affordable low-income housing with active living design principles. She followed
a cohort and demonstrated an improved BMI one year later. Many groups are programming existing
resources and ensuring that children are actually using the green spaces and trails. The University of
Southern California has done work regarding the benefits of urban parks on children's health. In terms of
diet, processed foods are major sources of environmental chemical exposures, thus efforts have been
made to encourage children to eat fresh fruits and vegetables. The New York City Commissioner of Health
recently applauded the efforts of the Vision Zero campaign to reduce motor vehicle injuries related to
shorter crossing distances, pedestrian islands and plazas, bike lanes, and other design changes. Other
efforts include an "Obesity and the Environment" fact sheet from the University of Michigan, Columbia
and WEACT materials promoting "Eat Fresh," a BPA wallet card from the Mount Sinai Children's
Environmental Health Center (CEHC) along with NEEF prescriptions for nature. Dr. Galvez concluded her
talk by emphasizing the important role research plays in providing evidence to enact policies, and that
everyone plays a role in shaping health communities and promoting children's health.

Session 7a Questions, Answers, and Comments

Susan Korrick, Brigham and Women's Hospital, commented that she and her team were doing green space
mapping in their New Bedford cohort to see how distance to parks and playgrounds affects various health
outcome measures. When they did not see what they expected, they looked closer and found that the
quality of the urban parks and playgrounds was horrible. She asked if they had recommendations for
determining park and playground quality. Dr. Galvez responded that her team had partnered with New
Yorkers for Parks, a group that systematically evaluates the quality of parks, and did end up seeing positive
associations. Their reports are available online for neighborhoods they have completed. Dr. Peterson
mentioned there was a group in Boston that catalogued parks. Dr. McConnell commented that it would
be a good community outreach project to recruit a group of students or interested people to do some fast
grading of city parks to try to streamline for research and policy purposes. Another audience member felt
this initiative would tie into the current push at the federal level for citizen science efforts.

The next audience member asked Dr. McConnell if he was aware of anyone looking into the impact of air
pollution regulation in concert with anti-smoking regulation. The questioner wondered if anyone had
looked at data from areas where legislation has made smoking less frequent, from an ecological method,
and in relation to obesity rates. Dr. McConnell responded that studies have looked at what happens when
smoking is banned with regard to other health outcomes. His team recently published a paper looking at
lung function growth in three large cohorts, ages ten to 15 years, and how it changed in relation to
pollutant exposure over different key periods. He said the same thing could be done with BMI, but it has
not been done yet. It could not be done with secondhand smoke (SHS) in his cohort because CA has been
quite successful at reducing SHS and in utero smoke exposure, so the sample sizes would not be large
enough.

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Leyla McCurdy, Health and Environment Consulting, contributed to the previous park discussion, saying
there is an excellent model in Washington D.C. where park quality information has been integrated into
medical records. The lead pediatrician for the effort is at the Unity Community Health Center. Volunteers
helped graded all the parks in Washington D.C., including many George Washington School of Public
Health students.

Session 7b - Exposome

Moderated by Claudia Thompson, Ph.D. National Institute of Environmental Health Sciences

Using a Risk Assessment Framework to Integrate Epigenetic Outcomes with Exposome
Assessment for Neurodevelopment

Elaine M. Faustman, Ph. _ versity of Washington

Dr. Elaine Faustman's presentation focused on lessons learned in developing an exposome for children's
health center cohort studies. Cumulative exposure studies require data at the individual, household, and
community scale and across life stages but depend on a variety of sources for information, including
biological and environmental measurements and survey data.

The life-stage construct is at the center and is therefore critical to consider when studying children's
health, along with social determinants of health, location, chemical exposures, physical and social
environment, biology, and behavior. Dr. Faustman's study was inspired by Chris Wild's explanation of
exposome and system biology, which suggests that external, internal, and specific external component
data can be layered to provide information for individuals in a population. This systems-based approach
for evaluating pesticide exposures was applied in the children's cohort study. The study acquired
farmworker and non-farmworker couple and children information at the individual level for 15 years,
household location at the community level, levels of 40 organophosphates pesticides (OPs) applied within
the community at the exposure level, acetylcholinesterase levels at the early biologic response, and the
genomic profile. The study used the environmental public health continuum to compile the pesticide
exposure pathways and community-based participatory research to determine the genetic susceptibility
and molecular mechanisms, particularly to determine the early biologic effect of pesticide exposure across
communities.

The goals of the study were to determine the factors that affect pesticide exposure and response,
establish if the genotype or phenotype can identify key genes that metabolize OPs that can improve
prediction of exposure, create pesticide assessment tools that incorporate genomics multiplied by
exposure multiplied by time, and determine if an exposome-based approach could provide actionable
data to improve and implement effective exposure preventions. The exposome-based method was
applied to a study examining the impacts of OP and carbamate use on apples and potatoes in eastern
Washington State on children's health. The longitudinal study assessed pesticide exposure to farmworker
and non-farmworker children across seasons (spray versus non-spray seasons). Samples were taken every
two days over multiple years. OPs are episodic (i.e., short half-lives), which allowed easier definition of

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exposome behaviors. The focus was on take-home pathways of exposure in the home or the individual
contamination level. The study measured multiple biomarkers of exposure, the parent compounds
chlorpyrifos (CP) and azinphos methyl (AZM), nonspecific diakyl phosphate (DAP) metabolites, and specific
CP and chlorpyrifos-methyl metabolites. Dr. Faustman presented the metabolic scheme for CP and noted
that a fair amount is known about CP, such as CP involvement in generating the reactive toxin and its
ability to react with PON-1, which causes genetic variation, to produce the nontoxic chemical tricresyl
phosphate (TCP). Less is known about azinphos methyl, but it is a prime compound that was found and
used in many of the children's cohort studies.

The study found that concentrations of pesticides, such as dimethylthiophosphate (DMTP), was higher in
farmworkers than non-farmworkers, and this pattern was also reflected in the children of farmworkers.
The study data were plotted against NHANES data, showing that the local population had DMTP levels at
concentrations 10-fold higher than national levels. This pattern was seen in farmworker children at
approximately a 5-fold higher concentration compared to national levels. The key to determining
exposure is to measure body concentrations at peak exposure and link peak exposure to the time of
agricultural use or pesticide application. The farmworker concentrations of DMTP reflect the spray season
versus non-spray season pattern across OPs, which demonstrates the spatial and temporal robustness of
this data and the importance of including season in the exposure model.

The study also used heat maps to display multiple exposures, such as pesticides, metals, and phthalates,
from multiple sources and metabolite concentrations in people over time to show exposure patterns. The
map showed that most children in the area were exposed and experienced multiple exposures, linking
exposure to occupation. House dust was not linked to metabolite levels, emphasizing the need to build a
database that supports this research. Another unexpected finding of the study was that farmers who did
not apply the pesticides had the highest concentration of pesticides, indicating that they are not wearing
the appropriate protective wear in the field.

The study used a multivariate correlational model to lay these exposures together, including data on
exposure levels in adults and children, car dust, and home dust. Correlations between these exposures
and metabolite concentrations in the blood and urine were made and then related acetylcholinesterase
(AChE) inhibition attached to the compound in urine and blood. In other words, all of the biospecimens
were linked to build the correlational model.

The study then examined the possible role that genetics play and found that, for the first time in a human
study, Atrazine (AZ-)AChE inhibition was not correlated with PON-1. Thus, the metabolism differences
between compounds need to be determined to interpret the results. DMET chip, which looks at 200 genes
that are associated with about 2,000 pathways in metabolism, was used for genomics and showed
polymorphisms of genetic variations at CYP3A5 with significantly different slopes as a function of OP dose,
which directly relates to AChE. The study also examined social determinants of health, publishing evidence
of a biomarker specific to ethnicity and income.

From this information, the study used a series of six different models to begin to combine the seasonal
differences, blood and urine measurements, and polymorphism information to determine if knowing the
exposome information and take-home pathway matter and if intervention is effective. An intervention
period took place between years one and four and found an 8-fold higher level of pesticide concentrations

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in people after the intervention. This was attributed to seasonality differences and, once corrected for
usage and land use differences, there was a 40-percent reduction in urine metabolites in children
observed after the intervention. This finding illustrates the need for genomics, metabolites, seasonal,
agricultural, and place-based information to use exposome information.

High-Resolution Metabolomics for Sequencing the Exposome

Dean IP .Jones, Ph.D. I Emory University

For several years, Dr. Dean Jones' Clinical Biomarkers Laboratory at Emory University has been working
to develop an affordable way to determine a broad coverage of exposure. The largest challenge to this
effort is the cost limitation of analysis, which helps explain why there are so little data available on the
50,000 chemicals or more to which Americans are regularly exposed. Dr. Jones explained that his
presentation, The Lightening Rod for Exposome Research, will highlight five key requirements for
sequencing the human exposome, including establishing a standard operating procedure (SOP),
sensitivity, quantifiability, affordability, and a central reference platform.

There is a need to establish an SOP that covers a broad range of exposures. Dr. Jones' lab is among a small
number of labs across the country with an SOP, but this is something that all labs should have moving
forward. Dr. Jones' lab well-established protocols from analyzing about 20,000 human samples. His lab
found ultra-high resolution mass spectrometry allows the rapid measure of a large number of chemicals,
and that it is important to use dedicated facilities when measuring human samples to avoid contamination
from experimental studies and maintain and improve equipment sensitivity. High abundance metabolite
samples can be run one at a time, but for most samples, including low abundance metabolite or chemical
samples, analysis should occur under rigorously defined, routine conditions with internal standards.
Calibrated pooled reference samples also should be used to ensure measurement confidence.

Detection is a challenge associated with the study of environmental chemicals, because most
environmental chemicals are present at orders of magnitude lower abundance. This requires sensitivity
of assays when measuring metabolomics. The high sensitivity of instruments understands the dynamic
range of detection and expands the limit to allow for measure of low abundance metabolites and
environmental chemicals. For example, Dr. Jones referred to a graph showing 4-chlorophenylacetic acid
abundance ten orders of magnitude smaller than the graph scale of 10"5, highlighting the level of HRM
instrument sensitivity and how critical sensitivity is for detecting environmental chemicals.

Quantifiability is critically important for regulators when addressing issues; however, U.S. regulators have
good information on less than 1,000 chemicals of the 50,000 to which the human population is exposed.
Due to such little information available, he argued one option is to relax absolute quantification
requirements to allow measurements within one order of magnitude of an unknown chemical to be used
to estimate environmental chemical levels. Dr. Jones showed a graph exhibiting all of the measurements
that can be taken with a single analysis: concentrations of glucose (mM), bilirubin (uM), cotinine (nM
range in non-smokers), and pirimicarb (subnanomolar range). This shows the range, sensitivity and ability
to quantify environmental chemicals and metabolites in low and varying abundance in the same analysis.

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Affordability is the driving force behind the development of routine HRM analysis methods. Dr. Jones
explained his objective to provide affordable ways to capture information on environmental chemicals. It
costs about $1 million annually to maintain one instrument with the current protocols. With Dr. Jones'
protocol, his lab is ableto measure 5,000 samples a year, costing $200 per sample, but his lab has validated
that the number of samples could be doubled to 10,000 samples annually, which would place operating
costs around $98 per sample. This number could also be increased to 20,000 samples annually, which
would cost about $50 per sample, depending on the analysis and how the system could be optimized. A
lower cost would allow access to a large amount of information with affordable means compared to other
analytical procedures. This could generate a large database to serve as a central reference platform. As
an example, Dr. Jones used a manuscript submitted by Doug Walker from NCI as an example looking at a
population of workers in China with high occupational exposure to trichloroethylene (TCE) that is
measured both in their blood and externally. If the TCE metabolites found in the blood are proportional
to the external measurements of TCE exposure, then these data can be used as a metabolomic platform.
This information can be used to validate the first part of the exposure paradigm and, at the same time,
provides information on the relationship of TCE exposure and biologic effect. A central reference platform
could work for a number of exposures, internal burdens, and biologic responses such as using uric acid to
measure renal function and measuring tryptophan to determine patterns in immune function.

Current methodologies and technologies are available and affordable to sequence the human exposome.
Using a uniform platform would allow the information to be anchored to one entity to ensure accuracy
and efficiency as work to sequence the exposome progresses.

Environmental Exposures in Early Life Influence Childhood Leukemia
Stephen M. Rappaport, Ph.D. | University of California, Berkeley

Dr. Stephen Rappaport's presentation focused on the use of dry blood spots to understand prenatal
exposures, particularly the involvement of prenatal exposure in childhood leukemia. Fetal exposure
during early development is critical to health and disease later in life, but fetal exposure is a challenging
topic to study.

In childhood leukemia, genomic studies show that genetic factors play a role in prognosis but account for
less than ten percent of cases, which indicates that exposures are important. Exposure research, such as
radiation, paternal smoking, and environmental chemicals, however, has not shown any relationship to
childhood leukemia. This, coupled with the average age of diagnosis in California of 4.6 years old, lead Dr.
Rappaport to investigate early-life and prenatal exposures. California hospitals save white blood spots
taken at birth for research, which Dr. Rappaport used a reference to the prenatal blood exposome. The
circulatory system integrates the entire human body, so the blood exposome is used to determine
exposure from a variety of factors from different sources. The blood exposome can be used to determine
exposures from outside the body (e.g., radiation and stress) and inside the body (e.g., lipid peroxidation,
gut flora, and diseases) throughout the individual's lifecycle. Because all exposures are inherently
chemical (either mediated or intrinsically chemical), the blood exposome incorporates all exposures and
can be used to compile multiple exposures into one analysis.

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Dr. Rappaport complied all data from studies that measured chemical concentrations in the normal
human population and plotted the 50 chemicals into a chemical space, organized by chemical structure
and prevalence (i.e., chemicals with similar structures were close together and chemicals with higher
blood concentrations was represented by a larger dot). About 100 different chemical classes were
represented with diverse origins (i.e., endogenous, food, drug, or pollutant), demonstrating the diverse
and complex exposures that are captured in a blood exposome.

The focus of Dr. Rappaport's study was to discover the non-genetic or exposure causes of childhood
leukemia by applying exposome-wide association studies (EWAS). EWAS matches biospecimens from
healthy and diseased subjects to compare the exposomes to identify the associations with a diseased
status and biomarkers of exposure. Once the associations are found, these areas in the exposome can be
targeted as biomarkers of exposures in a larger population to find causal exposures with fewer
measurements required.

In California, there are approximately 1,000 cases of childhood leukemia and 2,000 controls matched at
birth. Blood spots of these children are collected at birth and, in this study, are used to find the differences
in exposures. Having access to one-tenth of one blood spot on which to conduct the exposome analysis,
Dr. Rappaport developed an assay to measure small molecules and albumin adducts as measures of
exposure to get all of the necessary information from the small blood spot sample.

The assay uses solvent extraction that digests the protein and high spectrometry to determine untargeted
metabolomics or metabolomic adducts and altered proteins or protein adducts that are indicative of
highly reactive chemicals. Dr. Rappaport noted that it is essential to have dedicated equipment to take
measurements when you have small sample sizes. The first experiment measured small molecules in 100
childhood leukemia and 110 controls, matched by gender and ethnicity. The analysis measured 15,000
features, which measured greater than twice the background, in 20 minutes. The study found that 2,420
features in childhood leukemia cases positively matched the controls and 2,660 features in childhood
leukemia cases negatively matched the controls. Many of these matched features were derived from the
same molecules, allowing simple modification to reduce the features to digestible clusters. This left 5,000
features to compare between leukemia and control patients. The test of association with the cases of
childhood leukemia and the positive and negative matches to the controls created a Manhattan plot.
Some of the associations were significant before being adjusted or taking into account the error rate, so
covariates that significantly impacted the results can already be identified. This indicates the possibility of
identifying a factor associated with childhood leukemia.

The molecules were used to detect chemicals from a variety of sources including microbial metabolites,
fatty acids, and lipids. The protein adducts were used for information on reactive species and to
characterize exposures to reactive electrophiles, due to their inherent carcinogenicity. Human serum
albumin (HAS) was used, which is the most abundant protein in serum and has a residence time in humans
of 28 days allowing one to determine one month of exposure history. This adduct also has a nucleophilic
hotspot Cys34 that accounts for 80 percent of the antioxidant capacity of serum. Dr. Rappaport developed
an assay that digests the albumin, which results in peptides. If the peptide that contains the Cys34 reside
is detected, the peptide is studied using high-resolution mass spectrometry to obtain the peptide profile
and identify the area of modification. Once that area is identified, a method developed for this study

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acquires the peptide's signature ions to provide information on the presence and mass of the peptide
with Cys34.

The control blood samples were used to determine the prominent adducts. The study found a host of
different modifications collected from adults, children, and in-utero samples. This information is being
used to build the blood exposome for different life stages that might help illuminate the association
between what and when exposures occur and childhood leukemia, among other diseases.

Session 7b Questions, Answers, and Comments

Cindy Folkers, Citizens Beyond Nuclear, commended Dr. Rappaport on his research and noted some
scientists' reluctance to try new forms of radiation damage assessment and asked if he had examined
blood spots for center chromosome malformations. Dr. Rappaport responded that he was not sure about
chromosomal damage specifically, but one of his collaborators has been doing blood spot genomic
analysis to obtain DNA methylation for epigenetic information. Dr. Rappaport guessed that information
could be obtained from blood spot samples.

Gary Ginsberg, Connecticut Department of Public Health, stated it would make sense that signals for
leukemia in blood spot samples would be clearer than samples taken later in life and asked if the study
looked at the correlation between when leukemia occurs and changes in fetal blood spot signals,
specifically fetal binding adducts. Dr. Rappaport explained that he tried to identify adducts for use as
biomarkers. This correlation would likely not be found in this study as there is not additional information
other than what can be obtained from the blood spots themselves. Once a child is diagnosed with
leukemia, a lot of exposome changes occur, so analysis after diagnosis would not be particularly useful.

One meeting participant noted that all of the speakers' projects were very valuable. Referring to
populations in vulnerable communities when exposure is not extremely high, he asked about the use of
nonparametric measurements to analyze that problem and asked for the speakers' thoughts on the
available frameworks that could address health disparities in smaller concentrations. Dr. Faustman
explained that the cohort in her study was not large, with only 100 farmworkers and 100 non-
farmworkers. The samples were frequent and longitudinal and accounted for sampling variability,
allowing people to be used as their own controls for parametric and nonparametric data and making these
techniques relevant. Her study discussed some epigenetic markers but those measurements are small and
usually only measured once, making it difficult to control for genetic changes to account for small changes
in epigenetics.

Dr. Jones added that the field of epigenetics is moving toward taking epigenetic measurements during
regular physical examinations to build a repository of samples for everyone that could be studied every
year. This would also address the issue of large sampling sizes, close to 20,000 or 30,000 people, needed
to detect epigenetic changes or environmental exposures. Dr. Faustman explained that, typically, one
sample is run multiple times to account for variability. Dr. Rappaport added that the number of samples
that need to be run depends on the effect being measured. If the effect is large, then a small sample size
will suffice. Most gonadal white adipose tissues (GWATs) need large sample sizes to account for the small
effect.

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Jose Cordero, University of Georgia, asked Dr. Rappaport if he was examining populations with Down
syndrome that have high risk of leukemia based on genomics and exposomics. He asked what the
interactions are between Down syndrome and the exposome and if those interactions appear to be more
myositic or leukocytic.

Dr. Rappaport explained that the research he discussed was the first step in a longer process to address
Dr. Cordero's question, but he did find some preliminary data that looked promising. Dr. Faustman added
that Dr. Cordero has a paper that is expected to be published soon examining the correlation between
cancer and birth defect.

Session 7c - Reproductive Health

Moderated by Tracey Woodruff, Ph.D., M.P.H. | University of California, San Francisco

Updates on Environmental Effects on Reproductive Health
Marya Zlatnik, IVLO. | University of California, San Francisco

Representing the clinician's perspective on the panel, Dr. Marya Zlatnik presented on recent updates
regarding environmental effects on reproductive health. Pregnant women worry and inquire about many
exposures during prenatal care visits. Due to time limitations, she chose to focus on hydrofracking, a topic
that is receiving increased attention.

Dr. Zlatnik reiterated that this is a new topic and that the scientific knowledge base of the association
between unconventional natural gas extraction and pregnancy outcomes is extremely limited. She noted
PubMed contains only four related citations. In the absence of peer-reviewed literature, the media has
raised concern about possible health impacts due to the fact that chemicals used in the fracking fluid can
include known and/or suspected carcinogens, developmental neurotoxins, and volatile organic
compounds (VOCs).

Dr. Zlatnik discussed potential health impacts that have been identified using in vitro cell and animal
models. In one study, 39 well water samples were assayed in human cell lines for androgen and estrogen
activities. Of the 39 samples, 89 percent had estrogenic activity, 41 percent had anti-estrogenic activity,
12 percent had androgenic activity, and 46 percent had anti-androgenic activity (Kassotis et al. 2014). In
an in vitro assessment of 23 commonly-used fracking chemicals, estrogen, androgen, glucocorticoid, anti-
estrogen, anti-androgen, and anti-glucocorticoid effects were reported (Kassotis et al. 2015).
Furthermore, in laboratory mice exposed to a mixture of these 23 chemicals prenatally, male offspring
had decreased sperm counts, despite increased testes weight and increased serum testosterone levels
(Kassotis et al. 2015).

Dr. Zlatnik also described the human health effects reported in the four peer-reviewed studies available
in PubMed. The first study conducted in southwest Pennsylvania considered a woman's residential
proximity to fracking wells and evaluated its relationship with women delivering small-for-gestational-age
(SGA) infants. The exposure metric used was inverse distance weighted well count, which considered

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proximity and the number of fracking wells. In adjusted and unadjusted analyses, the authors reported a
positive association between proximity to wells and the risk of delivering an SGA baby (Stacy 2015). A
second study also used proximity to wells to estimate exposure, but examined the association between
exposure and preterm birth. The authors identified an increased risk of preterm birth among babies born
to mothers in the highest quartile of exposure (Casey 2015). Athird study used the number of wells within
ten miles of the infants' birthplace as a proxy measure of exposure to explore its potential relationship
with birth defects. The authors observed an increased risk of congenital heart defects and neural tube
defects and a slight decrease in preterm birth and low birth weight among infants in the highest tertile of
exposure (McKenzie 2014). The final study is an unpublished economics dissertation that considered
proximity to fracking wells and a number of health outcomes, including birth weight and Apgar scores. Dr.
Zlatnik stated that although the dissertation found a significant decrease in Apgar scores associated with
proximity to wells, she does not see the association as biologically plausible from a clinical standpoint. She
conceded, however, that the small number of inconclusive results warrant further study.

Dr. Zlatnik framed exposure to fracking as an environmental justice issue, noting that it is not easy to
evade and that often the effects are felt by those who are already disadvantaged. She discussed the
discrepancy between the geographic locations of the fracking wells in comparison to the residences of the
well owners in Texas. She added that the affected communities in Denton, Texas endeavored to have the
wells closed due to suspected health effects, but the moratorium they sought was overturned by the
state. Dr. Zlatnik emphasized this is not only a rural issue, pointing to an example of a fracking well in
South Los Angeles that sits near a university, low income housing, and a school for disabled adults.

Dr. Zlatnik closed by calling for more research to understand the potential health effects of hydrofracking
and urged clinicians to get involved to bring a clinical voice to policy making. She referred to the
moratorium on fracking in the state of New York as a prime example of health professionals coalescing to
urge a precautionary policy approach.

Impacts of Early-life Exposure to Endocrine Disrupting Chemicals on Puberty
John Meeker, Sc.D., C.I.H. | University of Michigan

Dr. John Meeker discussed his project at the University of Michigan CEHC that focuses on puberty. His
team also investigates the influence of EDCs on fertility and early childhood development. Dr. Meeker
began his discussion by explaining that the age at puberty onset has been declining. The specific age may
differ across countries, but the declining trend is consistent, especially among girls. He used a graph
indicating the timing of pubertal growth spurts and peak height velocity, two indicators of puberty onset,
among boys and girls between 1930 and 1970 to demonstrate the trend of declining age at puberty. He
displayed a second set of graphs showing onset of breast development and onset of menarche among
European girls between 1991-1993 and 2006-2008, which also indicated a trend of decreasing puberty
onset.

Dr. Meeker discussed the health impacts of early pubertal timing that have been documented in the peer-
reviewed literature. Health effects include increased risk of substance abuse and risky behaviors,
depression and other mental health disorders, and long-term health impacts such as cardiovascular

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disease, diabetes, and cancer. Dr. Meeker also noted that delayed pubertal onset has been associated
with increased risk of depression, substance abuse, and disruptive behavior among boys.

Dr. Meeker proposed that the decreasing trend in pubertal timing is a result of increasing exposure to
EDCs due to an exponential increase in chemical production in the post-World War Two era. He noted the
extremely high number of chemicals registered for commerce in the United States, of which few have
been thoroughly screened for toxicity. Although environmental health has traditionally been concerned
with increased exposures at the workplace or at toxic waste sites, repeated low-dose exposures are
becoming a focus within the field. The list of potential EDCs is growing, but currently, the main substances
of concern are phthalates, phenols, parabens, pesticides, flame retardants, and metals.

Dr. Meeker discussed the existing literature on EDC exposure and puberty, which is relatively small and
comprises studies that consider different exposures and use varying study designs. He noted the
limitations of using a cross-sectional study, which can obscure the direction of causality. For example, if a
cross-sectional study identifies an association between phthalate exposure and early onset of puberty,
that association may not be due to the exposure causing the outcome. Early puberty could have resulted
from individuals using more phthalate-containing personal care products than their normally-developing
peers.

Dr. Meeker focused on BPA and phthalates for his presentation. Phthalates are found in PVC plastics,
personal care products, and pharmaceuticals, while BPA is found in polycarbonate plastics, epoxy resins,
and thermal paper. Both classes of chemicals have been associated with adverse pregnancy outcomes,
fertility impacts, and childhood developmental effects, but their potential impacts on puberty are not well
studied.

Dr. Meeker gave an overview of his study at the University of Michigan called Early Life Exposure in Mexico
to Environmental Toxicants (ELEMENT), which is a longitudinal cohort study of pregnant women and their
offspring in Mexico City. Nine phthalate metabolites and BPA were measured during each trimester of
pregnancy to estimate in utero exposure. Children were also followed until age 8-14 years at which time
phthalate BPA measures were collected. The health outcomes of interest included Tanner stages for
genitalia size, breast size, pubic hair development, and testicular volume; age at menarche; and serum
reproductive hormone levels.

Dr. Meeker explained that phthalates and BPA were measured in nearly all study participants, but the
intra-individual variability in metabolite measurements was high, which underscores the need for
measuring exposure at multiple time points. Results indicated reduced odds of genitalia development
(Tanner Stage >1) and pubic hair development at the time of the study visit associated with some specific
phthalate metabolites in boys. In girls, the research team observed increased odds of menarche at the
time of study visit, but reduced odds of breast development. He concluded his presentation by noting that
the research team is continuing to examine exposure during in utero development and is currently in the
process of increasing the study's sample size.

The Pros and Cons of Testing Patients for Toxin Exposures
Susan Buchanan, M.D., M.P.H. | University of Illinois at Chicago

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Dr. Susan Buchanan posed the question of whether clinicians should screen pregnant women for exposure
to toxic exposures. She admitted that this is a controversial question, to which she does not have the
answer, but her hope was to start a meaningful dialogue around the topic. She introduced the U.S.
Preventative Services Task Force (USPSTF), which is an entity that makes evidence-based
recommendations about clinical preventative services such as screenings, counseling services, and
preventive medications. USPSTF assigns each of its recommendations a letter grade based on the strength
of evidence and the balance of benefits and harms of a preventive service. To receive a high-level-of-
certainty score, the available evidence must be based on studies that assess the effects of the preventive
service on health outcomes. She underscored the importance of focusing on potential utility to improve
health outcomes when considering new screening recommendations, such as screens for environmental
contaminants among pregnant women.

Dr. Buchanan used exposure to methylmercury in fish as her case example. Clinicians encourage pregnant
women to consume fish because it is a source of high-quality, low-fat protein and is high in
polyunsaturated fatty acids, especially the omega-3 fatty acids eicosapentaenoic acid (EPA) and
docosapentaenoic acid (DHA). Fish is recommended for its advantageous impacts on duration of
gestation, birth weight, and infant visual acuity, but particularly because of its association with improved
child neurodevelopment scores. However, fish is also contaminated with methylmercury, and there is a
well-established dose-response relationship between maternal methylmercury concentrations and
adverse effects on childhood neurodevelopment.

Dr. Buchanan noted that in order to screen a population for those at risk of adverse health outcomes, a
"safe" concentration cutoff must be established. She pointed out that the literature indicates incredible
variation in both the range of observed maternal methylmercury levels and the levels at which adverse
effects have been detected, which makes screening difficult. Adding to the complexity is the fact that
many observed associations occurred below EPA's current reference dose (RfD).

Dr. Buchanan stated that there are currently no guidelines for screening for methyl mercury in pregnancy.
The Alaska Department of Health universally screens women of childbearing age for methylmercury
exposure and follows up with women who have methylmercury concentrations in hair at or above five
parts per million (ppm). Around 10 percent of the Alaskan population had hair samples with
concentrations greater than one ppm, which is the current EPA RfD. The literature otherwise does not
contain examples of screening pregnant women for methylmercury exposure although a few studies have
suggested that such screening is needed.

Dr. Buchanan discussed what a screening for methylmercury exposure might involve. She described an
analysis she conducted to determine the potential results of screening of women of childbearing age using
the EPA RfD as the level of concern and NHANES methylmercury concentrations in blood. The results
indicated that using a simple universal blood draw approach yields fairly high sensitivity (96 percent) and
specificity (99.4 percent). However, asking women about their frequency offish consumption first, and
then, depending on the answer, pairing it with a blood sample increases the specificity to between 99.7
and 99.9 percent. Introducing the frequency of fish consumption question avoided 50-91 percent of the
blood tests that would have been administered under the universal screening approach.

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Dr. Buchanan also discussed whether screening should be based on ethnicity. She noted that NHANES
data indicate that Asians have a higher population prevalence of elevated methyl mercury levels.
Universal screening among this population yields relatively high positive and negative predictive values.
However, among other ethnicities that do not consume as much fish, these values are significantly lower,
illustrating that universal screening would not be an efficient approach within these subpopulations.

Dr. Buchanan noted two ongoing projects that are currently exploring different screening questions for
methyl mercury among pregnant women in tribal clinics in Minnesota as well as in prenatal care clinics in
the Great Lakes states more broadly.

Dr. Buchanan also noted that two published studies reporting on the success of methyl mercury exposure
screening programs have also been effective in reducing exposure. In the first study, recreational anglers
with elevated levels of methyl mercury in hair, who were informed of their exposure and advised to
decrease their consumption, had reduced hair concentrations by 30 percent after receiving this advice.
Furthermore, in a study that informed high-end fish consumers of their methyl mercury levels and advised
consumption of low-mercury fish, nearly all high-end participants (65 out of 67) reduced their blood levels
below five ng/L after receiving this advice.

Session 7c Questions, Answers, and Comments

Dr. Shaina Stacy, Brown University School of Public Health, pointed out that she is the author of the first
paper that Dr. Zlatnik discussed that evaluated the association between proximity to fracking wells and
risk of having a SGA baby. She said her research team also found a lower risk for low birth weight, when
considered as a dichotomous outcome, forthe mothers in the highest exposure quartile. Dr. Brown agreed
with Dr. Zlatnik that the inconsistency highlights the need for more research.

A participant commented on the issue of clinical provider compliance with screening guidelines. On the
west coast, where lead concentrations are relatively low, risk-based screening of children is also low. Dr.
Buchanan replied that there is a disconnect between CDC guidelines and actual clinical medical practices.
Dr. Zlatnik said that one of the reasons that physicians may not follow the guidelines is a legitimate belief
that they should not conduct the screening.

A participant asked Dr. Meeker about his pubertal timing results, specifically about his hypothesis
regarding the inconsistency in the directions of odds ratios both across and between genders. Dr. Meeker
responded that one reason is that the results were based on varying phthalate metabolites that act on
different hormonal axes. He conceded that he presented brand new data that are still in the process of
being analyzed and interpreted.

Paul Wax, American College of Medical Toxicology, said that it is becoming more common for patients to
request a test to determine their exposure to environmental chemicals. He stated that the data on lead
and mercury are relatively abundant compared with data for other chemicals and urged caution when
discussing such tests with patients as it is not clear what a given concentration means. He also commented
on the variation among laboratories in terms of quality of methods and accuracy of test results. He agreed
that more research is necessary in the area of environmental exposures and screening of both children

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and pregnant women, but acknowledged that researchers and clinicians should move forward consciously
and cautiously. Another participant agreed, stating that these test results are often returned as the
individual's percentile within the population's overall exposure with no explanation of what the toxic level
is or is thought to be.

Wayne Garfinkel, U.S. EPA Region 4, recalled a meeting several years prior in which concerns were raised
over the appropriateness of using hair as a screening tool to assess pregnant women's methylmercury
exposure; he also mentioned there were also concerns related to laboratory procedures for analyzing the
samples. He said it seemed as though Dr. Buchanan was validating that specific screening method and
asked whether these concerns have been addressed. Dr. Buchanan stated that hair is considered a
legitimate measure of exposure, but noted that samples need to be sent to legitimate laboratories that
report results in absolute concentrations, not relative percentiles, and treat the sample before analysis as
samples can be contaminated by hair dyes or cigarette smoke. Dr. Buchanan reiterated that she does not
have an answer to the question of whether or not pregnant women should be screened and added that
all of the issues raised are legitimate concerns.

One participant noted that increased blood lead levels are associated with delayed puberty and asked Dr.
Meeker whether decreasing lead levels at the population level could be responsible, at least in part, for
the observed shift in pubertal timing. Dr. Meeker commented that it is an interesting hypothesis.

Mark Miller, Western States PEHSU, commented that, for him, the bottom line question related to
screening pregnant women for toxic environmental exposures is: Will it result in clinicians giving different
recommendations than the common-sense fish consumption recommendations they would otherwise be
giving pregnant women? He wondered if there was truly an added value. Dr. Buchanan replied that his
concern is valid and the potential unintended consequence would be scaring women away from
consuming fish at all. Dr. Woodruff suggested giving women recommendations on the specific fish that
they might consume.

Laura Geer, SUNY Downstate, commented that some of the identified risk factors for blood lead screening
in pregnant women overlap with those that might be risk factors for mercury screening in the same
population. She explained that the population that she studies in Brooklyn, New York, is predominantly
Caribbean immigrants who are also heavy fish consumers. She added that there could be combined risk
screening for certain chemicals in specific populations that are at higher risk of exposure.

Session 8 - Keynote

Moderated by Margaret Karagas, Ph.D. | Dartmouth College

Little Things Matter: The Impact of Toxins on Children's Health
Bruce Lanphear, M.D., M.P.H. | Simon Fraser University

Dr. Bruce Lanphear gave a keynote address on the impact of toxins on children's health. He began by
explaining that conducting high-quality science and identifying important risk factors does not always

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translate into policy action, noting that it is crucial to understand why science isn't translated to
regulations or policy. Dr. Lanphear used the impact of toxins on the developing brain as a case study of
the difficulty of translating science to health protective action.

Brain-based disorders affect an estimated one in six to one in five children, but national surveillance
systems are lacking. These disorders are associated with a variety of genetic and environmental factors
including gender, nutrition, preterm birth, social stressors, the built environment, maternal depression
and genetic susceptibility. Dr. Lanphear noted that society is fixated on curing chronic diseases, but
pointed out that beyond vaccines and antibiotics, there are few "cures". As a society, he said, we fail to
acknowledge that the epidemic of death and disability due to chronic disease is largely a result of the
innovative technologies of the past: automobiles, tobacco, processed foods, and environmental toxins. As
an example, he stated that over one billion dollars spent on understanding the etiology of autism between
the years 2000-2010 was spent on genetic research; only 40 million (four percent) was spent on
environmental health research. Dr. Lanphear suggested that most of the cognitive or brain-based
disorders result from complex interactions of genes and the environment, underscoring the irrelevance
of genetic susceptibility if risk factors are identified and can be removed.

Prevention is particularly important in the context of children's environmental health, because the
developing fetus is uniquely vulnerable to environmental insults and the regulatory system used to
identify toxins is insufficient. The majority of established environmental toxins were only identified after
major environmental disasters. Dr. Lanphear pointed out that environmental toxins are insidious and the
disasters only represent just the tip of the iceberg. The population is exposed daily to air pollutants,
cigarette smoke, pesticides and other insidious toxins. He reiterated the importance of translating the
science into action.

Dr. Lanphear then showed a video he produced titled "Little Things Matter: The Impact of Toxins on
Children's Health," which illustrated the effect of low-dose exposure to several environmental
contaminants on neurodevelopment, specifically IQ, at the population level. The video may be viewed at
the following link: https://www.youtube.com/watch?v=E6KoMAbzlBw. Dr. Lanphear noted that the
studies discussed in the video suggest that there is no acceptable level for some of the most well-
established neurotoxins, which is troubling because our regulatory system assumes there is an acceptable
level. On the other hand, he said this can also be viewed as a hopeful message, because it implies there is
enough evidence to act in a manner that would prevent disease and disability.

Dr. Lanphear explained the concept of a supralinear dose-response relationship, which means there are
proportionately larger health impacts at the lowest levels of exposure. He pointed out that reducing these
low exposures would have the largest impact. He noted that about ten studies have observed supralinear
effects on IQ scores or academic abilities among children in association with lead exposures below five
micrograms per deciliter of blood. He noted, however, that this relationship is not just observed with lead.
Four studies indicate a similar phenomenon for PM2.5 and premature death from heart disease. A meta-
analysis of benzene exposure and leukemia shows a proportionately steeper increase in risk at the lowest
levels of exposure. This pattern has also been observed in studies of tobacco smoke and birth weight,
where the largest drop-offs in birth weight are seen at the lowest exposures. Dr. Lanphear described a
Scottish study that identified a 15 percent decrease in preterm deliveries and a 25 percent decrease in

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very preterm deliveries among non-smoking women after the establishment of a public smoking ban.
Furthermore, he cited a study in which a five microgram per deciliter increase in blood lead levels among
British pregnant women was associated with a two-fold increase in preterm delivery. Dr. Lanphear
discussed his own work, which found that a 10-fold increase in organophosphate pesticide exposure was
associated with a 150 gram reduction in birth weight and a half-week reduction in the duration of
gestation; the results were deemed as "clinically irrelevant/' by a commentator. Dr. Lanphear agreed that
it might be relevant if babies were exposed to only a single risk factor, but he underscored that this is not
the case; birth weight and pregnancy duration are impacted by the cumulative effects of a variety of
moderate, subtle risk factors, each of which result in small impacts on birth weight or gestational age.

Dr. Lanphear discussed the Prevention Paradox, which states that the majority of disease and disability
occurs in those who are at low to moderate risk. He used this idea to focus resources on children in the
top 2.5 percent of lead exposure as an example, acknowledging that it is efficient to address those at
highest risk. He explained that focusing resources on the 0.5 million children with exposures that exceed
the current reference value of five micrograms per deciliter of blood, which is associated with an average
loss of 6.1 IQ points, an estimated 3.1 million lost IQ points might be prevented. However, by only focusing
on those children, we fail to address the majority of the nearly 24 million lost IQ points that occur at
exposures below five micrograms per deciliter. He clarified that he is not suggesting that abandon those
who are at high risk, but that we need to strengthen a population or universal approach.

Dr. Lanphear commented that a population approach necessitates an emphasis on prevention, but the
focus, in terms of lead poisoning, has been on screening. He underscored the key to preventing lead
poisoning is remediating homes and removing the exposures before the child is born or before the mother
becomes pregnant, but this is not the primary practice. For every dollar spent to protect children against
lead hazards in housing, it is estimated that society benefits by anywhere between 17 to 220 dollars. To
put these numbers in context, vaccines, which have been touted as the single most cost-effective medical
or public health intervention in developed countries, have a cost-benefit ratio of 1:16.5. Although lead is
at least as cost-effective, the resources to prevent exposure are lacking.

Dr. Lanphear urged attendees that now is the time to give prevention a chance. He said that the scientific
evidence indicates adverse health outcomes are associated with environmental toxins, some of which we
know how to avoid. He noted that a starting place for individuals includes eating unprocessed foods,
minimizing the use of pesticides near the home, reducing the use of cosmetics and personal care products,
and supporting bans on smoking and cosmetic pesticides in addition to movements to update chemical
risk assessment policies and reduce the use of industrial pollutants.

Dr. Lanphear concluded by underscoring that society cannot continue to rely on cures. It has worked well
with infectious disease, but it has not worked as well for chronic disease.

Session 8 Questions, Answers, and Comments

A participant noted that Dr. Lanphear might also emphasize the environmental justice implications of
environmental chemical exposures, wherein the cost is borne by the majority of the population, while the
financial benefits accrue to a small percentage.

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A second participant commented that parents and the public health community struggle against
consumerism and peer pressure to combat the idea that adolescents need cosmetics or other products
that increase their environmental exposures. She noted that the exact behaviors the public health
community attempts to counteract are those they are socialized to carry into adulthood.

A third participant commented on food additives, pointing out that this is an important aspect of
exposure, because the population eats a diet increasingly consisting of processed foods.

A fourth participant noted that part of the struggle to act preventatively is that it requires upfront
investments. She proposed the idea of selling public health bonds that would be backed through
reductions in health care costs.

A fifth participant complimented Dr. Lanphear on his message of the impact of many small things and the
effectiveness of his graphics but urged him to capture cascading effects and the notion that these
relationships are much more complex. Dr. Lanphear agreed that it is an important message and informed
attendees that he is currently searching for a dataset that would allow him and his team to present on
synergistic effects.

Mark Miller, UCSF, commented that there are many deaths, diseases, and disabilities that can be
prevented, and that scientists must also play an advocacy role. He praised his colleagues at the meeting
who have passionately stepped into this role.

Frederica Perrera, Columbia University, commented that early-life exposures have ramifications
throughout the life course. As an example, she said even modest decreases in IQ may result in a less
productive life in terms of social contributions and earnings. She suggested it might be interesting to
attempt to monetize these impacts and emphasize the costliness of these seemingly small impacts. She
agreed with Dr. Miller that scientists must do their part to relay the importance of these small changes
and advocate for action.

Another participant noted changes to the health care system that have been brought through the
Affordable Care Act force providers to move away from a fee-for-service model toward primary
prevention. She stated that having a value-based dialogue might be very effective and that public health
and clinical data systems ought to converge. Dr. Lanphear agreed, saying that well-resourced, high-
performing health care systems do not necessarily translate into healthy children, particularly in the
United States. He noted that the major player is the environment in which they live.

Sally Darney, NIEHS, added to Dr. Lanphear's discussion of fresh and healthy foods by noting that the
marketing of foods derived from genetically modified organisms (GMOs) as safe does not consider
pesticide use.

Claire Barnett, Healthy Schools Network, reiterated a story of a California special education teacher who
returned to a refurbished classroom after spring break and, as a result, experienced severe asthma attacks
and had to be transferred to a different location. She asked whether there is any tracking of children who
experience exposures in what is otherwise considered an adult workplace (i.e., schools). Dr. Lanphear
agreed that it is important to consider health when building and renovating buildings and noted that the
green building movement is gaining traction.

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A final participant commented that perhaps existing disparities in health and access to health care are the
primary driver of the discrepancy between health care expenditures and health outcomes observed in the
United States. He urged focusing on underserved populations.

Session 9 - Community Outreach and Research
Translation

Moderated by Catherine Karr, Ph.D., M.D., M.S. | University of Washington

Environmental Health Perspectives (EHP): Your Partner in Research Translation
Sally Darney, Ph.D. | Editor-in-Chief, Environmental Health Perspectives

Dr. Sally Darney came to Environmental Health Perspectives (EHP) with 31 years of research experience
at the U.S. EPA. At EPA and previously as an educator at a junior college, she learned that perceptions of
health and biology differ widely across audiences, especially regarding reproductive health. Her
commitment to research and teaching health and well-being to a variety of audiences drew her to EHP,
where she continues to learn about the breadth of the environmental health field and the importance of
science communication The title of her talk references an inherent partnership between EHP and the
research community wherein EHP disseminates meaningful and relevant environmental health research
and knowledge to different audiences.

Dr. Darney explained the vision of EHP, which is "to publish credible, useful and impactful environmental
health research and information in ways that are relevant to and understandable by diverse groups,"
including the scientific community, regulators and risk assessors, health care providers, community
advocates, local governments, parents, educators, and the general public. She discussed the variety of
article types published by EHP which are intended to provide content that is "fit-for-purpose" to a variety
of audiences. Most EHP articles are peer-reviewed original research journal articles. Reviews are also
important as syntheses of information for readers who are not able to read the literature on a day-to-day
basis, but still want to know what has been learned in the past ten years, what it means, and how it can
be used (e.g., Uses of NHANES Biomarker Data for Chemical Risk Assessment: Trends, Challenges, and
Opportunities by Sobus et al., 2015). Commentaries are intended to be thought-provoking, and to
encourage debates and opinions on emerging issues about which there may be uncertainty and political
and economic implications (e.g., The NIEHS Super fund Research Program: 25 Years of Translational
Research for Public Health by Landrigan et al., 2015). The News section consists of articles contributed by
a variety of scientific writers, includes the most important topics that resonate with the broadest
audience, and are often translated into other languages made available through partnerships with
international organizations and journals. Letters and editorials are another type of article that
disseminates information. Dr. Darney also discussed the new category of Brief Communications, which
are more informational and intended to spread information on new resources, documents, websites, etc.

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The October 2015 issue of EHP included a focus on the influence of the environment on children's health
and development. Relevant News articles included, "Environmental Influences on Child Health Outcomes"
and "Just What the Doctor Ordered: Using Parks to Improve Children's Health."

EHP also publishes special collections including abstracts from the International Society of Environmental
Epidemiology, and the annual Children's Health Collection which draws from all types of EHP articles on
the topic. . Another EHP strategy is to pick a research article and write a corresponding news article to
make available both the technical documentation and data and a reader-friendly article for a broader
audience. For example, a 2014 study by J.R. Shelton et al. entitled "Neurodevelopmental Disorders and
Prenatal Residential Proximity to Agricultural Pesticides: The CHARGE Study" was published along with a
feature article by David C. Holzman entitled "Pesticides and Autism Spectrum Disorder. New Findings from
the CHARGE Study."

Dr. Darney reminded the audience that EHP is an open access and accessible without cost via the internet
(www.ehponline.org), and acknowledged NIEHSfor supporting the journals part of its mission of research
and translation across fields related to environmental health. She ended by inviting the audience to
provide suggestions for enhancing the relevance, accessibility, and usefulness of EHP moving forward.

Why Are Doctors Talking Toxics?

Patrice Sutton, MJP.II _ versity of California, San Francisco

Ms. Patrice Sutton explained that the science translated at her UCSF Children's Center revolves around
two facts: in utero exposure to toxic chemicals can harm not only children's health but also future
generations and pregnant women around the world have toxic chemicals in their bodies. She gave a brief
and incomplete history of why doctors talk about toxic chemicals, beginning with pediatricians' concern
about atmospheric testing of nuclear weapons raining down radioactive isotopes on children. This led to
the formation of a Committee on Radiation Hazards and Epidemiology of Malformations by the American
Academy of Pediatrics (AAP) in 1957, which served as the predecessor to the current Council on
Environmental Health. Arguments about funding between Congress and U.S. EPA coincided with AAP's
interest in moving beyond radioactive isotopes to toxic chemicals. This ultimately led to production of the
"Green Book," which is the "Bible" for pediatricians regarding toxic chemical exposure. In the 1990s, Ted
Schettler, Gina Solomon, Maria Valenti, and Annette Huddle, from Greater Boston Physicians for Social
Responsibility, published, "Generations at Risk: Reproductive Health and the Environment." This pointed
to reproductive health as the issue and highlighted the important role of reproductive health professionals
in prevention of adverse health outcomes in children.

Under the leadership of Alison Carlson, Linda Giudice, and Tracey Woodruff, UCSF held a summit on
reproductive health and the environment in 2007, bringing together 400 leaders of reproductive health
professionals, pediatricians, and government agencies. The UCSF Program on Reproductive Health and
the Environment was founded shortly thereafter. In 2012, U.S. EPA Administrator Lisa Jackson recognized
then American College of Obstetricians and Gynecologists (ACOG) President Jeanne Conry as an
environmental health champion, emphasizing the important relationship between reproductive health
professionals and government agencies involved with toxic chemicals. That same year, PEHSUs and the

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UCSF Pregnancy Exposure to Environmental Chemicals Children's Center helped organize a strategic
meeting in Chicago, made possible by support and funding from EPA and ATSDR. The meeting brought
together NIEHS, AAP, ACOG, the American Society for Reproductive Medicine (ASRM), and other health
professional societies and environmental agencies to endorse a common agenda about prevention.

In 2013, ACOG and ASRM issued a joint statement stating reproductive health professionals should pay
attention to toxic chemicals and take action in the policy arena. As leading women's health professional
societies in America, this represented the coupling of science and leadership in this area and set the stage
for global action. The International Federation of Gynecology and Obstetrics (FIGO), comprised of 125
countries and territories, held a World Congress in October 2015 in Vancouver for "Advancing
Reproductive Environmental Health for All." The organizing committee, consisting of WHO, UCSF Program
on Reproductive Health and the Environment, ASRM, ACOG, Society of Obstetricians and Gynecologists
of Canada, and the Royal College of Obstetricians and Gynecologists, met for over a year to produce an
opinion on reproductive health impacts of exposure to toxic environmental chemicals. Published October
1, 2015, they determined that it is very bad to expose pregnant women to toxic chemicals and made four
recommendations: 1) Advocate for policies to prevent exposure to toxic environmental chemicals, 2)
Work to ensure a healthy food system for all, 3) Make environmental health part of health care and its
delivery systems, and 4) Champion environmental justice. Twelve other health professional organizations
around the world endorsed this opinion, which cited 11 Children's Centers studies as a reflection of all the
science funded by NIEHS and EPA. A Summit on Shaping Our Planetary Legacy was held on October 4,
2015, to develop an action plan. The FIGO opinion was disseminated globally in multiple languages, which
received a lot of press coverage in the United States and Europe and included a large social media
campaign with infographics and a video that went viral.

Ms. Sutton emphasized that money from NIEHS and EPA helped the Children's Center leverage the
foundation money, giving them the legitimacy they needed to seek other funding for science that matters.
Reproductive health professionals around the world own, embrace , and want to act on the science and
FIGO has a Reproductive Developmental Environmental Health (RDEH) Work Group ready to bring the
recommendations discussed in the opinion to fruition.

Do No Environmental Health Harm - An Updated Oath
Jennifer Lowry, M.D. || Children's Mercy Hospital

Dr. Jennifer Lowry discussed translating science to health care professionals who tend to patients.
Wikipedia defines knowledge translation as the "umbrella term for all of the activities involved in moving
research from the laboratory, the research journal, and the academic conference into the hands of people
and organizations who can put it to practical use." Dr. Lowry explained that she sees patients at both an
environmental health clinic and one looking at children with adverse drug reactions, many of whom have
autism or ADHD. She discussed the medications being taken by children that come to see her; for example,
Matthew was on "serotonin support" and "methylation support." She suggested some practitioners
prescribe "methylation support" to change a person's epigenomes to "fix" ADHD or autism, but argued it
is impossible to "methylate everything." She consulted a website that had a list of clinics and academic

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medical centers that are associated with the Walsh Research Institute and discovered a list of biochemical
features of autism, including "undermethylation," and a list of popular biochemical therapies for autism,
which included "Methyl-B12 and other methylation therapies." This is only one example of misuse of this
data as other practitioners are recommending similar "treatments" Dr. Lowry argued that the published
science has been misinterpreted this way and emphasized the need to do better translation of this science
to avoid these misinterpretations.

Dr. Lowry explained the hierarchy of evidence to move through ideas, case series, cross-sectional studies,
case-control studies, cohort studies, randomized controlled trials, metanalyses, and systematic reviews.
Clinical trials are important, but not specific enough for application to the individual patient, and
population-level epidemiologic association studies also are not useful for the individual patient. NIEHS
and EPA Children's Centers engage in community-based, participatory research, and PEHSUs engage in
clinical consultation, education, and referrals. Both are community partners that work to achieve
translation, as well as training the "next generation." The PEHSU website also has fact sheets, FAQs, and
other resources, and support for general public education and community and legislative advocacy.
PEHSUs want to work with researchers and professionals and the Children's Centers to do a better job of
informing the public with regard to science. AAP's Council on Environmental Health has developed policies
based on published science, although it acknowledges the difficulty of basing policy on population
association studies. Healthychildren.org is another resource; AAP also provided a list of terms searched
for on the site, which included water quality and lice rather than lead and epigenetics, which
demonstrates how the public's view of what is needed differs from that of researchers.

Dr. Lowry finished her talk by providing an example of what can be done to improve research translation.
In the October 2015 issue of EHP, an article was published along with a "comment" in response. If
Children's Centers partner with a PEHSU, a similar approach can be used to point out important
publications and discuss how the results can be used and interpreted. She concluded with the story of
canaries and coal mines, explaining how canaries were used to test the air quality of coal mines to ensure
it was safe for workers to go down. Unfortunately, children are currently serving as our canaries in the
coal mine.

Simplifying the Complicated: Leveraging Digital Media for More Effective Community
Engagement and Research Translation
Carolyn Murray, M.D., M.P.I _ tmouth College

The Children's Environmental Health and Disease Prevention Research Center at Dartmouth is focused on
understanding the health effects of in utero and early life exposure to arsenic. Arsenic exposure is difficult
to communicate effectively to parents and the public. People associate arsenic with poison and cancer
and also link it to apple juice, which is a beverage consumed primarily by children despite pediatrician
recommendations to the contrary. The Food and Drug Administration (FDA) assessed arsenic
concentrations in commercial apple juice and reported that children's exposure was not significant, yet
Dr. Oz, a trusted health source for a large segment of the population, raised issues with the FDA's
assessment and stated that apple juice could pose a health risk to children. This demonstrated the

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hallmarks of challenging risk communication. Risk perception is increased when exposures cannot be
seen, tasted, or smelled; if the exposures disproportionately affect children; are involuntary; and have
health effects about which experts disagree. Adding to this perfect storm of risk perception elevation, the
media covered the issue, and researchers published new information on the presence of arsenic in chicken
feed and rice.

Under the leadership of Dr. Margaret Karagas, the Dartmouth Children's Center has been systematically
identifying the sources of arsenic in the food supply, beginning with in utero and maternal exposure
through well water and in food, focusing on rice products and continuing on through infancy and into
childhood. The amount of arsenic these women and children consume is expressed in their urine and in
other biomarkers, raising the challenge of how to best communicate this in a responsible way. Dr. Karagas
presented findings to the Food Advisory Committee at the FDA last year, which is looking at vulnerable
populations in their own regulatory policy. The FDA is being asked to set regulatory limits for arsenic in
rice and rice products, but they are in the midst of their risk assessment, and no decision has been made.
In the absence of a regulatory limit, we must determine what to tell pediatric health care providers and
parents about arsenic in their food in the interim. Dr. Carolyn Murray explained that the message is
confusing and conflicting. For example, "organic" brown rice syrup can have toxic levels of arsenic, and
"healthy" snacks are often sweetened with it. There is also the conundrum of brown rice versus white
rice; brown rice is considered healthier from a glycemic index and nutritional standpoint but can have
higher arsenic concentrations. The Children's Center sought a way to get this message across to
consumers to empower them without frightening them.

To tackle this issue, the Dartmouth Children's Center partnered with the Digital Arts Leadership and
Innovation (DALI Lab) in the Department of Computer Science at Dartmouth College. The DALI Lab's first
idea was to develop an app, where you could scan the barcode of a food to find out how much arsenic it
contained. This idea did not make it off the group, but as the students of the DALI Lab grappled with other
ideas, they learned the science. This iterative process helped clarify messaging, and got both students and
the Children's Center researchers excited about using digital media to present an environmental health
message. Dr. Murray found it inspiring that, in terms of thinking about environmental health, the current
generation gets it, wants to own it, and has the ability to display the concepts in creative ways.

Ultimately, they told the science-based story of how arsenic gets in food visually using an interactive tool.
The undergraduate students developed logos and other ways to make these complex concepts more
simple- a very difficult task. The tool describes what arsenic is, and the ecosystem effects causing it to be
persistent in the environment, emphasizing the interplay with the food system. The tool follows the life
cycle of arsenic, moving through bedrock wells, soils contaminated by pesticides from use decades ago,
arsenical antibiotics in chickens and manure, apples, rice, and farmland. In all of these stages, the viewer
can see how arsenic migrates through the system by water. The tool emphasizes rice products as the most
common source of dietary exposure. The bottom of the interactive tool focuses on the idea of
empowerment and education, including tips on how to minimize arsenic exposure with links to more
detailed information on the science and ways for parents to protect their kids given the lack of current
regulation.

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When it was launched, a write-up appeared in the Partnerships for Environmental Public Health (PEPH)
Newsletter, which led to an increase number of hits on the Children's Center's Facebook page and
website. It has only been out a few months, but they are able to track website traffic and Facebook
responses related to the DALI Tool. Dr. Murray said they were looking for further leveraging opportunities,
perhaps in EHP, to encourage the use and dissemination of science-based digital tools funded by EPA and
NIEHS. Dr. Murray is eager to hear other ideas about how to leverage this further, and encouraged the
audience to consider digital tools moving forward. The non-science community is harnessing this, and Dr.
Murray stressed the need for the science-based advocacy side to do the same.

Build It and Will They Come? Lessons Learned from A Story of Health e-Book
Mark Miller, M.D., M.P.H. | University of California, San Francisco

Dr. Mark Miller opened his presentation on outreach to healthcare providers by discussing a survey of
pediatric oncology providers regarding their environmental health training experience. Six percent of
survey respondents indicated they received the basic training, in taking an environmental history. Fifty
percent responded that they were uncomfortable speaking with patients and their families about
environmental exposures. Ninety-two percent of respondents indicated they would value more
information and education related to environmental health.

In order to fill the knowledge gap amongst practitioners, the Western States PEHSU collaborated with the
Boston and San Francisco Physicians for Social Responsibility and a team of pediatricians to develop the
Pediatric Environmental Health Toolkit (PEHT). The Toolkit includes information about key environmental
exposures to children and their health effects of concern and how parents might reduce their child's
individual exposures. The Toolkit is now available as an online continuing education course. Dr. Miller
acknowledged that the PEHT developed as a single exposure-single outcome paradigm. Given the
complexity of environmental health impacts, however, the Western States PEHSU developed a new CE
program, the Story of Health with partners including PSR, ATSDR, California EPA, the Collaborative on
Health and the Environment, and Science and Environmental Health Network.

A Story of Health centers on an event—a family reunion—and illustrates complex environmental health
issues based on stories told by several reunion attendees (http://coeh.berkeley.edu/ucpehsu/soh.html).
In one story, 3-year-old Stephen was occasionally exposed to pesticides at a garden center owned by his
parents. His mother who noticed his lack of energy and fever took him to the doctor who ran blood tests
and diagnosed him with childhood leukemia. The story addressed other potential risk factors. Another
story addressed the impacts of family and community stressors on the exacerbation of childhood asthma.
The stories included short embedded videos with clips of experts discussing the topic in further detail.

Dr. Miller underscored that one of the lessons learned was that people prefer approachable, visually-
pleasing, real-life scenarios as a tool for learning as opposed to reading a textbook. Dr. Miller noted that
a second lesson learned was that simply making a good product available online does not ensure its proper
use; repeated outreach is necessary. He explained that the funding partners were able to leverage their
listservs, webpages, blogs, and social media sites to increase the use of A Story of Health as tracked by the
views of the embedded videos.

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Dr. Miller noted that the continuing education course has been downloaded 2,500 times, and 1,500
individuals have registered with the CDC to receive the continuing education credit. Approximately 3,000
hours of continuing education credit had already been given. Those who completed the course were given
the opportunity to comment on its format, and A Story of Health received much positive feedback. Ninety-
seven percent of those responding indicated that "the content and learning materials addressed a need
or gap in my knowledge or skills." Ninety-six percent agreed that "the instructional strategies (lecture,
case scenarios, figures, tables, media, etc.) helped me learn the content." Furthermore, 94 percent said
they "will be able to apply the knowledge gained from this activity to increase or maintain (their)
competence."

#duetoepigenetics #whatdoesthatmean ffmustbewoodooscience
Susan Murphy, Ph.D. || Duke University

Dr. Susan Murphy presented on what can be done when a scientific message is misconstrued. She
conveyed personal examples of research findings being mistranslated by the media and what can be done
when that occurs.

Example one: After Dr. Murphy received funding for a study to assess whether the increased risk of ADHD
associated with tobacco smoke exposure in utero is mediated by epigenetics she was contacted by a
reporter who then came to her office to discuss her research findings. During that discussion, Dr. Murphy
included details of her own family. She shared that her mother had smoked while pregnant. She also
shared that her oldest son was born prematurely and died of hepatoblastoma at three years old. She
revealed that her youngest son was diagnosed with autism and her daughter has ADHD. When the story
was published, it was entitled "From Great Grandma to You." She underscored the importance of only
discussing topics you are comfortable with seeing in print.

Example two: Dr. Murphy's postdoctoral research included work on gene imprinting in sheep, during
which she and her coauthors identified the mutation that gives rise to the 'callipyge' phenotype, which
causes fast-twitch muscle hypertrophy and reduced adipogenesis. The sheep with this phenotype have
larger buttocks than their wildtype counterparts. Nature wrote an accurate representation of the study,
but the media ran stories titled "Why Your Bum Looks Big in This" and stated that the experts found that
if "you are endowed with larger size buttocks than the average person... it's in your genes." Dr. Murphy
assured participants that she and her coauthors never made such comments.

Example three: The issue of public perception on the topic of epigenetics. She described what she found
after a quick Google search of "epigenetics." One of the search results was for the Epigenetics Healing
Center, which did not discuss epigenetics on its website in any form. Another result was for Dr. Soram's
Enlightened Medicine website, which described epigenetics as "the future of medicine." Dr. Soram was
quoted as saying that he had studied epigenetics for many years and "one of Mother Nature's strongest
epigenetic molecules is vitamin D." Dr. Murphy said that fact was simply false and Dr. Soram could not be
found in PubMed.

Dr. Murphy admitted that epigenetics is an extremely complex topic that is difficult to communicate. She
explained that communication is easier among scientists in the same laboratory or same field who share

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a high level of understanding. Communication becomes increasingly difficult among audiences with lower
levels of understanding, such as scientists in other fields, general undergraduate students, your family
physician, or the press. Analogies are a common tool used to communicate ideas that are new or difficult
to grasp, and analogies can be used to elucidate epigenetics. One example analogy described the genome
as the hardware of a computer and the epigenome as the software of the computer, both of which are
required for the machine to function. Dr. Murphy used another analogy that described the genome as a
road (without lines, signs, or traffic signals) and the epigenome as the lines, signs, and signals that control
traffic. She added that the methyl groups that attach to DNA at certain positions are, in effect, the
molecular stop signs that tell the cellular machinery to skip that region of the DNA. Dr. Murphy noted that
while analogies are sometimes helpful in explaining a complicated subject, they lack any real resemblance
to what actually occurs and can be easily misconstrued.

Dr. Murphy concluded by noting the importance of high-quality scientific communication. Scientific
curiosity is growing, and public awareness combined with citizen science means there is more urgency to
translate research findings. Fragmented and misleading information at the infancy of understanding has
the potential for harm. She underscored that the taxpaying public who funds much of the scientific
research deserves careful and meaningful explanations of epigenetics, so that they appreciate it as an
important research area that deserves funding.

Session 9 Questions, Answers, and Comments

Darryl Hood, Ohio State University, commented on the focus on prenatal exposure and the maternal-fetal
unit, saying that preconception exposures are also important. He stated that the American College of
Obstetricians and Gynecologists (ACOG) are developing preconception and maternal guidelines. He asked
whether the panelists and their organizations interface with ACOG on these matters. Dr. Miller responded
that the PEHSUs are collaborating with ACOG on research efforts, and that these research efforts center
around preconception and maternal environmental health. Dr. Lowry replied that she is unsure about
whether or not a maternal or child guideline for exposure will be written. She said the key to treatment is
preventing the exposures in the first place.

Becky Ofrane, U.S. EPA Region 2, stated that the Dartmouth parallax came across her Facebook newsfeed
during the summer and she then shared it on her own page, saying it was a fun way for both children and
adults to learn about the health effects associated with arsenic exposure. Her most cynical friend
commented that nothing says fun to kids like arsenic! She noted that, despite the critics, it is important
to continue to share information in any way possible. Ms. Ofrane also pointed out that each regional EPA
office has a children's health coordinator that works closely with their community. She encouraged
attendees to contact their regional children's health coordinator when they need assistance with
community outreach.

Elaine Cohen-Hubal, U.S. EPA, commented that the priority within EPA's Office of Research and
Development (ORD) is actionable science. She noted that the CEHCs are producing fundamental science
that identifies important signs, and she wondered what additional science is needed to move the research
toward policy translation so the Agency can act. She noted that different aspects of children's

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environmental health science are at different levels of maturity, so the focus will be on specific decision-
making contexts and case examples that can highlight the tools that academic and government
researchers have been developing and refining. Finally, she encouraged the scientists and science
communicators to think critically about their scientific message, especially about what may or may not be
actionable. Dr. Murray replied that scientists have a responsibility to anticipate the unintended
consequences of their science and scientific messages. Dr. Catherine Karr (University of Washington)
pointed out that, traditionally, communication is something tacked on at the very end of a research
project; however, scientists must consider effective communication in the design phase of a study to
ensure the results will be actionable and translatable. Dr. Patrice Sutton (UCSF) responded to Dr. Cohen-
Hubal's inquiry about what additional science is needed to move toward policy action. She noted that the
UCSF Navigation Tool and similar tools developed by the National Toxicology Program are designed to
synthesize the current scientific evidence for decision-making. She stated that there is an abundance of
published environmental health science information; the next step is not to produce more science, but to
gather the evidence in a rigorous way and deliver it to the decision-makers. Dr. Lowry replied that the
scientific messages do not only reach decision-makers; they also travel through the internet. Healthcare
providers and patients may interpret aspects of the science as "fixable" without understanding the
nuances of the findings. She underscored the importance of reaching out to the unintended audiences.

Wayne Garfinkel, U.S. EPA Region 4, noted that most of the work conducted by the regional Children's
Environmental Health Coordinators and their teams is community-based work within vulnerable
populations, which is similar to the work done by the PEHSUs and the CEHCs. He asked how the Children's
Environmental Health Coordinators might better learn from the work of PEHSUs and CEHCs in order to
make a bigger difference within vulnerable communities. Dr. Sally Darney said that Dr. Garfinkel is getting
at how success in one community might provide a useful lesson for other communities. She suggested
reinstating printing case studies in Environmental Health Perspectives as a way to share success stories
more broadly. Dr. Lowry commented that it will also be critical to reach out to populations and
organizations that are further outside the box, but are still somewhat interested. Dr. Miller responded
with two points. In response to Dr. Cohen-Hubal's comments, he said that decision-makers can still act on
science even if the evidence base is not fully developed. He added that studies are more valuable, in terms
of what actions should be taken, when they reflect real-life scenarios. Dr. Miller provided a few examples
of how to reduce exposure among vulnerable populations, including reducing traffic-related air pollution
and eliminating mold within schools. Dr. Murray responded that she has used environmental health tools
to bring stakeholders together in her own work. She partnered with community-based pediatric and
family medicine clinics and used a GIS mapping tool to indicate the geographic probability of increased
water contaminants within the state of New Hampshire and overlaid this with locations of the clinics to
raise awareness of clinicians about environmental exposures they may want to discuss with their patients.
Dr. Murray stated that these types of tools will play a critical role in converging the healthcare and public
health communities although specific collaborations will vary geographically. Dr. Garfinkel agreed that
different communities will have different needs. He added that he considers PEHSUs as one of the major
tools in improving children's environmental health. Dr. Murphy underscored the importance of
prevention with a focus on pre-pregnancy populations. As an example based on her own work on
epigenetic changes associated with prenatal tobacco smoke exposure, she said that PEHSUs might help

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facilitate the message of potential harm to high school students as a means of prevention within the pre-
pregnancy population.

Ed Levin, Duke University, agreed that prevention is key, but urged the panelists to not forget the
individuals who have already been adversely impacted. He stated that those affected are typically the
most motivated to encourage action, and are likely more interested in studies considering therapeutic
treatments and treatment effects. Dr. Lowry replied that it is our job to consider treatment as well as
prevention of ongoing exposure. She reminded the group that they must be careful when discussing
treatments because the message may be misinterpreted as illustrated by several of the panelists' earlier
presentations. Dr. Miller added that there are no intervention studies in the literature base to draw upon.
He used lead as an example, pointing out that there are plenty of data on its effects and data indicating
that treatment is ineffective. He also noted that the animal literature shows an enriched environment
may be beneficial and noted that more data of this type in human populations will be critical. Dr. Levin
agreed that there is no magic bullet solution, but wondered whether the evidence that an enriched
environment can attenuate the effects of lead exposure warrants interventions. Dr. Miller replied that it
is always good practice to reinforce the importance of beneficial exposures among parents who may be
worried about exposures over which they have little control, such as eating a healthy diet and reading to
their children. Dr. Lowry urged caution when applying results of a population study to a single individual,
noting that relying on scientific data that is not ready to support an intervention may actually cause
serious unintended harm, as she has seen in her own practice. Dr. Sutton commented that people who
are directly impacted (either exposed or already experiencing health impacts) intervene by changing their
environment. Dr. Murphy agreed that it is important to make sure affected individuals do not feel
abandoned. She highlighted the importance of frequent communication and outreach, even on projects
that have not yet produced concrete steps forward, to reassure the communities that researchers are
working hard to make progress.

MaryGant, NIEHS, retired, commented that education and communication programs need to help young
people understand the science so that they can make better, more informed value judgements. She gave
the example of individuals undervaluing the science of vaccinations and the recent increase in specific,
vaccine-preventable diseases. She said the goal should be improving the analytical capabilities of the
public to empower good decision-making around health care.

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Session 10 - The Pediatric Environmental Health
Specialty Units Present: Emerging Topics in Children's
Health

Moderated by Carl Baum, M.D., M.Sc. | Yale University

A Blueprint for Protecting Children's Environmental Health: An Urgent Call to Action
Nsedu Witherspoon, M.P.H. | Children's Environmental Health Network

Ms. Nsedu Witherspoon began by explaining that the Children's Environmental Health Network (CEHN) is
a national nonprofit organization that has been working 23 years on the same core issue: making sure
that children grow up in safe, healthy environments and live to their full potential. To achieve this mission,
CEHN has several goals: to stimulate and support prevention-oriented research; to elevate public
awareness of environmental hazards to children; to educate community members, health professionals,
policy makers, and key public health leaders in developing strategies to prevent exposures to these
hazards; and to promote the development of sound public health and child-focused national policy. CEHN
has worked to support peer-reviewed science, to translate that science effectively in a variety of ways for
multiple stakeholders, and to develop child protective policies based on the vulnerabilities of children.
CEHN acknowledged that over the past 20 years, there has been much advancement in children's health;
however, they are discouraged that, despite these efforts, trends for some health outcomes are still
moving in the wrong direction. In response, CEHN has recommitted itself to reversing those negative
trends. For the past three years, CEHN has been building momentum in constructing a new blueprint for
protecting children's health, organizing a number of meetings to bring together a variety of experts with
a range of perspectives—including communication experts, legal experts, business leaders, community
leaders, policy and science experts, and health economists. CEHN was lead author of a background paper
that described U.S. advances in children's health and gaps and opportunities moving forward. Last
October, CEHN was invited to a Wingspread summit in Racine, Wisconsin coordinated by the Johnson
Family Foundation; Ms. Witherspoon explained that this was a big deal because the Foundation
recognized a groundswell of interest in children's health and they wanted to be a part of it. All of this has
led to what CEHN calls "A Blueprint for Protecting Children's Environmental Health: An Urgent Call to
Action".

Ms. Witherspoon reviewed five themes of the Blueprint and their respective call to actions. The first
theme was to mobilize society to take action. Science has demonstrated irreversible and severe risks to
children's health and urgent action is needed. A comprehensive strategy to communicate environmental
health issues facing children is essential. The second theme was to marshal the engine of the economy to
manufacture and utilize safer products. We must encourage the production and purchasing of safer
products by creating a market demand. The third recommendation was to build the political will in
institutions of government; this will has waned over the years and is necessary for transformative change
to occur. Society also should better recognize elected leaders who are champions of children's
environmental health, take charge in developing talking points and briefs on key children's environmental

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health issues for elected officials, advocate for a Children's Bill of Rights, and promote children's health in
all policies. The fourth recommendation was to establish a vibrant children's health environmental
community in order to strengthen and align efforts. Bridging collaboration among health care
professionals, urban planners, the environmental justice movement, and the public (including
marginalized communities) is critical. Ms. Witherspoon referenced the social determinants of health
discussed by Dr. Gail Christopher in her talk the previous day as being central to this theme.

For the fifth and final theme, Ms. Witherspoon described the importance of strengthening our
understanding of environmental impacts on children's health; this is essential for effective action. This
can be accomplished by developing a research agenda to address knowledge gaps; crafting ways to
overcome funding obstacles for research in the area of pediatrics and prevention; developing
comprehensive mass media materials as part of the communications strategy; disseminating information
to engage members of the public; and creating curricula for elementary and high schools on children's
environmental health issues to ensure the next generation is well equipped to handle these issues.

This Blueprint is a high-level framework and resource; CEHN is very proud of its leadership and ability to
bring others onboard. Ms. Witherspoon concluded by saying that this work is also part of the 21st century
imperative discussed by Dr. Christopher the previous day, which should be critical to all the work being
done.

Potential Health Hazards of Increasing Cell Phone Use
Laura Anderko, PhD., M.S., R.N. | Georgetown University

It is well known that technology is evolving and becoming more widespread. Cell phone usage has become
part of the fabric of society and is integral to the lifestyle of many people. There are an estimated 6.9
billion cell phone subscriptions globally. More frequent and longer calls mean that global society is
spending more time on the phone; that creates some potential hazards. Dr. Laura Anderko displayed a
graph showing how cell phone ownership in the United States has gone from 65 percent in 2004 to 91
percent in 2013. Cell phone usage by children has increased greatly; three out of four 12-year-old children
own a phone, and 53 percent of children own a phone by age six. There has been increased marketing to
get kids to start using cell phones earlier and earlier. These trends bring about concerns of emerging health
risks, both thermal and nonthermal.

Like a microwave, a cell phone is a nonionizing radiation device; our exposure to radiation increases as it
gets closer to our body. Dr. Anderko showed a graphic illustrating the differences between the
penetration of radiation in the brains of five- and ten-year-old children versus an adult. Children have
thinner skulls and more water in their brain, thus they are much more likely to absorb radiation. In 2011,
the International Agency Research on Cancer (IARC) classified cell phones and other wireless devices as
possibly carcinogenic to humans due to radiation emissions. Cell phone health advisories are cropping up
worldwide, including in Belgium, Australia, France, Turkey, and Italy. Another issue of concern related to
cell phone usage is the status of regulatory standards; 19 years ago the FCC created standards for cell
phones that have remained unchanged despite dramatic increases in average cell phone use.

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The risks associated with cell phones include putting it close to the head, putting it in the pocket, using it
during pregnancy (exposing the fetus), using it excessively, and operating with low bandwidth. There are
serious concerns for kids who are exposed to cell phones for long periods of time. Dr. Christopher Wild,
Director of IARC, said in 2011 that "it is important to take pragmatic measures to reduce exposure such
as hands-free devices or texting" particularly for children. Looking forward, there have been many studies
but currently nothing is conclusive or causal; additional studies will be coming out in the near future. Dr.
Anderko mentioned that for some studies, significant differences in results are seen depending on
whether the telecommunications industry funded the study. Mobi-Kids is an international, multicenter
study that examined the risk of brain cancer from exposure to radiofrequency fields in childhood and
adolescence. The National Toxicology Program is finishing up its third phase of study on rats and mice
exposed to cell phones for nine hours/day in utero and through adulthood. Dr. Anderko concluded her
talk by saying that we should rethink marketing phones to children and reconsider what we as clinicians
are telling people regarding the pros and the cons of cell phone usage; the data are still emerging, but
there are legitimate concerns out there.

Studies of Children's Exposure to Chemicals on Artificial Turf Fields

Gary Ginsberg, Ph.D. || Connecticut Department of Public Health

Dr. Gary Ginsberg described a risk assessment conducted by the Connecticut Department of Public Health
(CTDPH) that evaluated exposures to chemicals in ground-up recycled tires used in artificial turf fields.
This risk assessment was performed in response to community concern over the potential health impacts
to children exposed to the chemicals in the turf. Dr. Ginsberg noted that community concern associated
with this potential exposure stemmed from the perception that tires contain toxic elements. He clarified
that tires are in fact treated differently from everyday household trash accepted into community landfills.
This special treatment for tires, however, is less about toxicity and more about preventing fires that can
occur when tires are exposed to high temperatures, which release naphthalene, other PAHs, BHA,
phenols, benzothiazole, and other hazardous chemicals. In conducting the risk assessment, CTDPH sought
to provide scientific data to address public concern over this issue.

Dr. Ginsberg described a headspace analysis conducted for crumb rubber—the material used in the
artificial turf tested by the CTDPH. In a headspace analysis, material is heated to cause the off-gassing of
chemicals, which are captured and analyzed using gas chromatography mass-spectrometry (GS-MS).
Results of headspace analysis help to identify the chemicals that might be explored in subsequent field
analyses. Dr. Ginsberg noted that during these lab analyses, crumb rubber released toxic chemicals,
including naphthalene and other PAHs, phenols, and benzothiazole. In order to fully understand the
potential risk to children's health associated with these chemicals, CTDPH conducted a risk assessment
using real-life exposure levels and evaluated the risks in the context of other environmental exposures.

Unlike previous assessments, the CTDPH study conducted personal monitoring, evaluated both outdoor
and indoor fields, considered acute risks, and focused the risk assessment on exposures to benzothiazole,
a chemical released specifically by tires. CTDPH field sampling included personal monitoring for
particulates and gases at hip height and stationary monitoring at locations up- and down-wind of the field

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at hip height and ground level. Stationary monitors were used to evaluate inhalation risks posed by VOCs,
SVOCs, particulates, lead, and zinc during active play in mid-summer. The results of the exposure analysis
identified relatively faint signals from PAHs (0.01-0.1 ng/m3), mostly naphthalene, at four outdoor fields.
A stronger signal of PAHs (around 100 ng/m3) was observed at the single indoor field. Benzothiazole
registered relatively faint signals at the four outdoor fields, while a markedly increased signal was
observed at the indoor field. Increased particulate concentrations were not observed at outdoor or indoor
fields, and no increase in lead was observed at outdoor fields. Dr. Ginsberg added that new crumb rubber
rapidly "weathers" (within 10 to 30 days) with chemicals off-gassing at a high rate, after which much lower
exposures would be expected.

For the risk assessment, CTDPH evaluated a scenario that assumed three hours of play on the field per
day over a total of 138 days during the year at a moderate level of exertion. The risk assessment did not
identify a significant increase in noncancer or cancer risks associated with acute exposures at outdoor
fields. Marginal cancer and noncancer risks associated with acute exposures were observed at indoor
fields. Dr. Ginsberg noted that the results of the CTDPH study are consistent with findings from a 2006
Norway study that identified elevated VOCs on indoor fields, but minimal increases in risk levels. He also
mentioned a 2008 analysis out of New York City that found no significant increase in VOCs or particulate
exposures in outdoor fields and a 2009 EPA analysis of outdoor fields that also observed no significant
increase in VOCs.

Despite consistent findings that indicate low risks associated with crumb rubber in artificial turf, Dr.
Ginsberg explained that the public remains concerned for several reasons. A recent study from Yale
University reported results of a crumb rubber chemical analysis, without a field study, that identified
carcinogens and irritants. He noted that media reports on the anecdotal collection of cancer cases being
tracked by the women's soccer coach at the University of Washington have also contributed to public
concern. Dr. Ginsberg mentioned the importance of using solid epidemiologic studies, which not only
enumerate cases but also identify the size of the source population (e.g., the risk denominator) when
assessing risk. He also underscored the influence of self-reporting and the absence of personal exposure
histories, especially given potential pesticide exposures on natural grass fields.

To conclude, Dr. Ginsberg emphasized the importance of advanced safety testing for children's products
and conducting exposure assessments under an actual use scenario. He reiterated that the CTDPH did not
identify elevated risk levels associated with exposure at four outdoor fields although slightly higher risks
were found at indoor fields. He also noted the uncertainty surrounding new, "unweathered" fields, and
the possibility that higher exposures could occur on warmer days than those evaluated by the CTDPH. He
closed his presentation by repeating that the CTDPH is not endorsing the use of crumb rubber and
reminded the audience that concerned communities have several alternative options in terms of materials
for artificial turf fields.

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Not So Pretty - Endocrine Disrupting Chemicals in Cosmetics and Perfumes
Katie Huffling, R.N., M.S., C.N.M. | Alliance of Nurses for Healthy Environments

Ms. Katie Huffling presented on EDCs in cosmetics and perfumes. She began her presentation by asking
the audience members to consider the number of personal care products they used that morning while
getting ready. She reported that the average American adult uses nine products daily, which translates to
over 125 individual ingredients each day. Further, over a quarter of American women and one in 100 men
use at least 15 products per day. Notably, the average teenage girl uses over 17 products daily. The extent
to which consumers use these personal care products is also relevant. Users are exposed to personal care
products daily via dermal absorption, inhalation, and ingestion, but the FDA has a weak regulatory
authority in the context of personal care products. The Federal Food, Drug, and Cosmetics Act (FFDCA)
was enacted over 75 years ago and does not give FDA the power to require premarket testing, premarket
approval, product recalls, or data reporting.

Ms. Huffling gave an overview of EDCs and how they act within the body. She explained that EDCs are
chemicals that interfere with the body's natural chemical messengers. They act either by blocking or
mimicking the actions of natural hormones. The growing fetus is extremely sensitive to EDCs. She noted
a wide variety of examples, but focused on a few chemicals in particular: parabens, phthalates, and
triphenyl phosphate.

Parabens provide antimicrobial properties in products such as deodorant, antiperspirant, shampoo,
conditioner, and lotion. These chemicals are so common that the average person is exposed to multiple
parabens from several sources each day. Parabens are estrogen mimickers and have been found in breast
tumor biopsies. Ms. Huffling cautioned that although this does not indicate causation, it has raised interest
in the ways the estrogenic properties of parabens may influence breast carcinogenesis. She noted a recent
study that showed the estrogenic effects of parabens was significantly amplified when combined with a
specific protein associated with breast cancer tumors. Parabens have also been observed to reduce sperm
production and testosterone levels in males. Finally, to highlight the importance of everyday exposures
to parabens, Ms. Huffling pointed to a cohort study of pregnant women and their newborns conducted in
Brooklyn, New York. Women in this cohort had the highest levels of methyl- and propyl-paraben among
pregnant women ever measured, and 95 percent of the cord blood samples contained at least one
paraben. To avoid parabens in personal care products, consumers should lookforthe "paraben-free" label
or check the ingredient lists for chemicals ending in "-paraben."

Phthalates are used in a wide variety of products, but are typically listed on ingredient labels simply as
"fragrance." Dibutyl phthalate (DBP) has typically been used in nail polish to increase the flexibility and
durability of the product. In recent years, manufacturers have phased out the use of DBP due to consumer
concern over potential health impacts. Phthalates are a component of everyday exposures, and these
EDCs are inhaled or readily absorbed through the skin. Phthalates are found in the majority of the
American population and impact a number of biological pathways. Some phthalates act as a weak
estrogen and act in combination with estradiol. Phthalates also interfere with androgen receptors. In
animal models, in utero exposures to phthalates have been shown to disrupt the development and

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function of both male and female reproductive systems by interfering with the production of testosterone
and estradiol, respectively. In humans, phthalates have been associated with decreases in anogenital
distance in male infants, which is an indicator of feminization of external genitalia. In a study of breast
development among young girls, participants with premature breast development had significantly higher
levels of phthalates than participants with normal breast development. To avoid phthalates, consumers
should look for phthalate, DEP, DBP, DEHP, and fragrance/parfum on product labels.

Ms. Huffling also mentioned triphenyl phosphate, which manufacturers are using to replace DBP in nail
polish. Triphenyl phosphate is a suspected EDC and has been shown to absorb quickly through the skin
after nail polish application. The possible health consequences are not currently known, but potentially
regrettable substitutions will continue to occur until the regulatory system is updated.

Maternal Exposure to High Levels of Electromagnetic Fields During Pregnancy and the Long-
Term Health Impact on Their Offspring

Pe-iwii Li, M.D., Ph.D., M.P.H. | Kaiser Permanente Division of Research

Dr. De-Kun Li presented on the adverse health effects of electromagnetic fields (EMFs) on fetal
development and children's health. He began by underscoring the importance of accurately measuring
EMFs when considering the exposure-health effect relationship. He explained that there is a
misconception that EMFs are not associated with adverse health effects, but this misconception is due
primarily to inadequate exposure measurements conducted in the majority of studies exploring this
association. Another factor contributing to this misconception is that most studies of EMFs and health
outcomes investigate cancer. Cancer is an insensitive health outcome to study due to its long latency
period and rare incidence and requires reliance on retrospective exposure assessments. He summarized
that inaccurate exposure measurements and insensitive health outcomes will, by definition, yield results
that indicate no association.

Dr. Li provided a historical overview of the concern over EMF exposure. Concern over EMF exposure from
power lines—which give off low-frequency EMFs—began 20 to 30 years ago. He pointed to the initial EMF
study by Wertheimer and Leeper (1979), which found an association. Dr. Li thinks that although the study
was based on crude exposure measurements and an insensitive health outcome (childhood leukemia),
Wertheimer and Leeper were incredibly lucky to find the association. But luck, by definition, cannot be
easily replicated, said Dr. Li. Subsequent studies followed the template of Wertheimer and Leeper and
resulted in many of them reporting null findings, contributing to the misconception that there are no EMF-
associated health risks. Recently, there has been a revival in concern over EMF exposure as cell phone
usage becomes increasingly common and evidence of adverse health effects associated with magnetic
field exposure emerges. He noted that determining the true association between high-frequency cell
phone EMF and various health outcomes may require conducting prospective studies which can take time
to complete. But we have to start collecting data now. At the same time, we can borrow from findings
based on studying low-frequency exposures which may be directly applicable to high-frequency EMF
exposure such as cell phone and other wireless devices. He likened the finding of high- and low-frequency
EMF exposure to the findings of health effects from alcohol consumption—for example, alcohol could

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come from wine, beer, hard liquor. However, they all contain alcohol. It is hard to argue that the finding
of alcohol's effects from studying beer does not apply to alcohol from hard liquor or wine. However,
ironically, some are arguing that the health effect observed by studying low-frequency EMF, which is more
advanced than high-frequency EMF research, does not apply to high-frequency EMF health effects, wiping
out significant amount of existing scientific evidence of adverse EMF health effect.

Dr. Li provided a high-level overview of the prospective cohort studies he conducted to explore the
association between low-frequency EMF exposure during pregnancy and the occurrence of miscarriage
as well as childhood asthma and obesity. Pregnant women wore personal meters to monitor their EMF
exposure for 24 hours during the first or second trimester. Subjects kept a log of their daily activities and
indicated whether the activities were representative of a typical day during pregnancy. Results of the
study indicated that high-level of EMF exposure during pregnancy is associated with high risks of
miscarriage, childhood asthma, and childhood obesity. Due to insufficient time, Dr. Li encouraged
conference attendees to read his peer-reviewed publications on this cohort for more details on study
methodologies and findings.

Trends in Consumption of Artificial Sweeteners and their Metabolic Effects
Allison Sylvetsky, Ph.D. | George Washington University

Dr. Allison Sylvetsky began by providing examples of artificial sweeteners as well as their common brand
names—e.g., sucralose (Splenda), saccharin (Sweet 'N Low), and aspartame (Equal). She also provided
examples of noncaloric, plant-based natural sweeteners such as rebaudioside A, commonly known as
Stevia. All of these products are low calorie and are potent in terms of their sweetness, but they differ
greatly in their physical and chemical structures. Because they are low in calories, artificial sweeteners are
used as a substitute for high caloric sugars in sweetened beverages. There is a public health emphasis to
reduce the consumption of these sugar-sweetened beverages and switch to low calorie alternatives.
Artificial sweeteners are not just in soft drinks labeled as diet or light. They also exist in packet form and
are used in some highly consumed foods that are eaten by children. Their use is more obvious in products
that say "diet" or "light," but sometimes there are hidden artificial sweeteners in the food supply. For
example, they may be found in high fiber sweet cereals, lower carb ice creams, and high fiber oatmeal.
Other non-diet applications of artificial sweeteners include toothpaste, mouthwash, and children's
medications to increase palatability and compliance.

Using NHANES data, Sylvetsky et al. published consumption data in 2012 showing a clear overall increase
in consumption of artificial sweeteners in children, a trend driven by the increase in artificially sweetened
beverage consumption. The trend for diet sodas has stayed consistent, while consumption of light and
diet fruit juice and diet lemonade has increased dramatically. One concern is there are inconsistent
recommendations regarding artificial sweetener consumption in kids. In 2010, the AAP reported that
artificial sweeteners are "inadequately studied for use among children," but, in 2009, the ADA stated that
"children can safely use artificial sweeteners." Much of this inconsistency is due the discrepancy among
studies. Epidemiological studies have shown a positive association between artificial sweeteners and body
weight and adverse metabolic outcomes; in contrast, randomized trials have shown marginal weight loss

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and modest benefits associated with artificial sweetener consumption. An epidemiological prospective
cohort study in San Antonio showed that as consumption of diet soda increased in adults, so did BMI. Two
randomized control trials recently published in the New England Journal of Medicine showed that when
kids replace sugar beverages with artificially sweetened beverages, there are modest benefits on weight.
Dr. Sylvetsky mentioned that this discrepancy could be due to reverse causality in that artificial
sweeteners may not be causing weight gain, but rather that individuals who are already overweight are
choosing to consume diet soda as a weight management tool. Mechanisms have been proposed and
supported in animal models that have provided a connection between artificial sweeteners and adverse
outcomes. These mechanisms include altered taste perception (higher preferences for sweetness),
altered nutrient absorption, changes in gut hormones, caloric compensation, and changes in dietary
patterns.

Sylvetsky et al. recently published a study showing there are artificial sweeteners present in human breast
milk, even in mothers who did not report consuming artificial sweeteners. Their data showed that
saccharin, sucralose, and acesulfame-potassium are all present in human breastmilk; however, the
implications in terms of taste preferences in infants are not yet known. Data from rodent studies have
shown that when rodents are exposed in utero to artificial sweeteners, they have higher preferences for
sweetness in adulthood. Another emerging area of study examines the influence of artificial sweeteners
on the gut microbiome; some recent studies have shown that artificial sweeteners change the gut
microbiome with regard to glucose intolerance and increased host energy harvest. Whether this is true in
humans is currently unknown. Dr. Sylvetsky acknowledged that researchers in this field have their work
cut out for them.

Children's Health Impacts of Climate Change
Perry Sheffield, M.D. || Mount Sinai Hospital

Dr. Perry Sheffield presented on the impacts of climate change on children's health. She began her
presentation by noting that an average global temperature increase of less than one degree Celsius may
not seem like a major problem, but it is enough to drive changing rainfall patterns, expand oceans, and
melt major ice shelves. Even in low-emission scenarios, models indicate that ten million Americans are
currently living in areas that will be submerged at high tide in year 2100. At the current emission rate, this
number increases to over 26 million Americans.

Dr. Sheffield stated that increases in atmospheric carbon levels impact plant life. Carbon-rich
environments enable plants such as poison ivy and ragweed to grow bigger and release more pollen.
Furthermore, research on agricultural crop growth shows that high levels of carbon result in lower protein
and micronutrient content across common whole-food crops (wheat, rice, soybeans, maize, sorghum, and
field peas); this is notable given that approximately three billion people worldwide depend on these crops
as their primary source of micronutrients.

Dr. Sheffield pointed out that actions to reduce emissions can also have health benefits. One way to
reduce personal emissions is to consume less meat, which might also have positive impacts on saturated
fat levels in our bodies and incidence of heart disease. Furthermore, green school buildings, with high-

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performance lighting, improved ventilation, and temperature controls, have shown decreased energy and
water usage in addition to reductions in absenteeism and asthma. In addition, changing transportation
patterns—such switching from a car to a bicycle for one's daily commute—has been shown to decrease
the risks of certain cancers and heart disease.

Dr. Sheffield pointed to the growing number of post-secondary academic training programs and
professional job postings related to climate change and human health. She reiterated the importance of
understanding the health implications of climate change and underscored the value in framing mitigation
and adaptation approaches around their associated public health co-benefits.

Global Children's Environmental Health
Kathleen Alexander, Ph.D., D.V.M. | Virginia Tech

Globally, infectious disease is one of the most important causes of mortality and morbidity in children.
Dr. Kathleen Alexander explained how the environment plays an important role in increasing childhood
exposures to pathogens; not only in terms of the incidence, but also in the manner in which pathogens
move across the landscape. This is particularly true for children who are minorities and/or living in
poverty. Landscapes are changing; there is more overlap between humans and animals, and we cannot
always predict the consequences of these changes. In low resource environments, such as Botswana,
where Dr. Alexander has conducted extensive research, there are additional challenges; if there is a
disease outbreak, we do not always know what caused it. Most research has used case data that are
influenced by health-seeking behaviors and driven by culture that changes according to geographic scale
(regional to national to community to household). In an effort to improve children's health in these low
resource areas, we must try to integrate behavior and culture, including for example, consideration of
health behaviors that may be used by a family may engage in to mitigate some of these impacts can have
unintended health consequences.

Dr. Alexander explained how diarrheal disease provides a unique opportunity for asking important
questions about how host attributes interact with the environment to create multi-causal infectious
disease dynamics. Water is the dominant source that brings people together with animals across diverse
landscapes. Annual bimodal diarrheal disease outbreaks in children under five years of age are observed
and significantly correlated with declines in water quality, meteorological and hydrological dynamics, and
land use impacts from both animals and humans. For example, in Botswana, huge populations of
elephants are constrained in their water access because of competition with human development in dry
regions which can impact water quality in a spatially associated manner. Diarrheal disease dynamics in
Botswana at the national level also correlated with meteorological variables, identifying increased
vulnerability to the impacts of forecasted climate change for the region. These observations and trends
make it apparent that environmental drivers may be critical in understanding infectious disease dynamics
in these systems and need to be considered by researchers.

Dr. Alexander next described how multidrug antibiotic resistance in animals, both domestic and wild, is
common in her study site in Africa where drugs and antibiotics are freely used and available for human
use. Level of multidrug resistance may be influenced by life history attributes of the animal (i.e., where

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and how they live). For example, there were higher levels of multidrug resistance in animals that live in
the water (versus just drinking it), animals that live with humans, and animals that were at the top of the
food chain. This information provides mechanistic insight into this global health threat and can be used to
pinpoint pathways of antibiotic resistance exposure and transmission. Dr. Alexander concluded by
reiterating that environmental factors are important in driving infectious disease incidence and
researchers need to consider these factors in their studies. In addition, what we learn at the global level
is important for children's health internationally and here in the United States given our increasingly
diverse population and the importance of health disparities that occur both internationally and
domestically and have important influence on the impact of infectious disease in general.

Session 10 Questions, Answers, and Comments

Diana Conway', Independent attendee, expressed concern about the elevated risk of adverse health effects
from exposure to artificial turf given the uncertainty surrounding unstudied chemical combinations. Dr.
Ginsberg clarified that he only studied five fields, and they are not sure if their sample is representative.
He reiterated that the study did not find much PM exposure outdoors and that crumb rubber off-gasses
quickly outside, although this is not necessarily the case indoors. He stated that together with the rest of
the published data, it does not appear that a large cohort study of crumb rubber is warranted.

Dr. Susan Buchannan, University of Illinois at Chicago, commented that she has received many phone calls
from concerned parents regarding these exposures. The participant asked Dr. Ginsberg to clarify the
potential risks of off-gassing and his confidence in the findings. Dr. Ginsberg stated that his study did not
identify an issue, and his task was to provide information to cities in his jurisdiction that would help them
decide whether they might use crumb rubber as a field material. He underscored that communities have
alternatives available.

Tracy Stewart, Independent Attendee, commented on the documentation provided by companies that
produce crumb rubber. She noted that the Material Safety Data Sheets suggest the use of personal
protective equipment when handling the chemicals involved in its production and wondered how it can
be safe for children to play on such a surface. Dr. Ginsberg replied that he studied exposures that occur
during the intended use of the product, not necessarily direct handling of the materials. He again
reiterated that communities have a number of choices in terms of field materials.

Devra Davis, Environmental Health Trust, commented on the growing evidence of male-mediated
teratogenesis and asked Dr. Li whether he has any data on the fathers and how he might set up a study if
he were designing one today. Dr. Li responded that he conducted a study of the effects of electromagnetic
fields (EMF) on sperm quality, which found that high-frequency EMF exposure is associated with increased
risks of poor sperm quality.

A participant asked Dr. Li what high-level EMF exposure equates to quantitatively. Dr. Li replied that the
actual numbers are less important than the relative exposures, though the average high-frequency
exposure measures around 2.5 millihertz and the 75th percentile is typically near five millihertz.

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Becky Ofrane, U.S. EPA Region 2, asked whether there is research being conducted that explores the
replacement chemicals for endocrine disrupting compounds. Ms. Huffling answered that phthalates are
being replaced with regrettable substitutes, as the current regulatory system does not require pre-market
testing. She added that even if industry identifies an adverse health effect, they are not required to notify
the Food and Drug Agency. Dr. Linda Birnbaum (NIEHS) added that regrettable substitutions occur
because it is easy to change one atom in a compound without changing the industrial process necessary
to manufacture it. She pointed out that this also likely does not alter the biological response.

A participant stated that cell phone technology has changed over time and asked whether the different
technologies have different risks. Dr. Anderko responded that the recent National Toxicology Program
study used the wavelengths currently emitted by cellphones. She pointed out that our cellphone use
habits and patterns have also changed. Dr. Li added that generally EMF associated with digital
technologies are lower, although the problem lies in the uncertainty of whether the effect is associated
with energy levels of the house. He noted that cell-to-cell communication uses weak EMF signals and
outside influences can affect cell division processes that have implications on fetal development and
oncogenesis.

Session 11 - Next Steps for Collaboration between the
Children's Environmental Health Centers and the
Pediatric Environmental Health Specialty Units

Moderated by Kimberly Gray, Ph.D. | National Institute of Environmental Health Sciences

Overview of Pediatric Environmental Health Specialty Units

Ruth Etzel, M.D., Ph.D. | Director, Office of Children's Health Protection, U.S. EPA

Dr. Ruth Etzel shared a story about one of the early experiences in her career that solidified her interest
in children's environmental health. She told about a previously healthy, happy, and energetic four-year-
old boy whose parents reported that he would not get out of bed, and was burying his head in his pillow
as if he were sensitive to light. When he visited the clinic, he was squinting due to photophobia and had
a rash, low-grade fever, leg cramps, and swelling, redness and peeling of his hands, feet, and nose. These
signs and symptoms were similar to those seen in childhood illnesses, including infectious diseases such
as measles and Rocky Mountain Spotted Fever. Environmental exposure to mercury can also cause these
signs and symptoms. Mercury poisoning is now rare because mercury has been eliminated from many
products. The four-year-old boy was diagnosed with mercury poisoning, or acrodynia, also known as "pink
disease," which is characterized by pain in the extremities, pink discoloration with desquamation of the
skin, hypertension, sweating, insomnia, irritability, and apathy. Pediatricians of the 1950s used to
diagnose acrodynia more frequently than today's pediatricians because mercury was contained in some
teething powders and other products. It was unclear how this healthy child had been exposed to mercury.
It turned out that the boy's family had had a fire in their home that completely burned the inside, and the

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family decided to repaint the interior walls. The child's father purchased 17 gallons of paint for this project.
The four year old boy was home during the time the painting occurred. Mercury had been used as a paint
preservative and mercury off gassed from the freshly-painted walls into the air. Because mercury is
heavier than air, its highest concentrations were near the floor. Thus, the four-year old child, who played
on the floor, had higher exposure to mercury than older children or adults in the family. Additionally, this
particular batch of paint had much more mercury added to it than was permitted.

This history and subsequent testing of the hone's indoor air by the Department of Health allowed doctors
to identify the actual cause of the child's acrodynia. The child's parents decided they did not want this to
happen to other children, so they shared their story. At the time, it was not required that mercury be
listed on the paint label. The family shared a video of the boy trying to get out of bed, and stumbling and
falling because his limbs were so painful. . The father brought the video to regulators at the U.S. EPA. EPA
quickly reached a voluntary agreement with paint manufacturers to stop adding mercury to interior latex
paints.

Dr. Etzel told this story, because it demonstrated the need for parents and physicians and health
departments and environmental regulators and industry to work together to prevent environmental
health problems for children. The clinicians and scientists working in the PEHSUs and CEHCs play an
influential role in bringing issues that arise in communities to the attention of researchers and regulators
working in federal agencies.

How Pediatric Environmental Health Specialty Units and Children's Environmental Health
Centers Can Inform Children's Environmental Health Policy
Sheela Sathyanarayana, M.D., M.P.I _ versity of Washington

Dr. Sheela Sathyanarayana shared her experiences working in multiple arenas and explained how these
arenas can work together to advance children's environmental health. She began with a tweet from
President Obama: "Every child should have the chance to fulfill their potential. #OpportunityForAII." Dr.
Sathyanarayana argued the goal that every child should have this chance despite their race, gender, zip
code, etc., is one where focus is needed as it has not traditionally been addressed in children's
environmental health. She showed a Venn diagram of the policy, research, and clinical areas and identified
the point in the middle where all three overlap as most desirable. Although most people feel comfortable
in their niche spots, she emphasized that they can contribute to the overall progress of children's
environmental health no matter where they fall on the diagram.

AAP, EPA, and state and federal government regulators read the research of the Children's Centers and
observe the clinical trends and translation efforts of the PEHSUs to inform the development of children's
environmental policy. For Dr. Sathyanarayana, EPA's CHPAC, of which she has been a member for six years
and the chair for four years, demonstrates this. Experts from state government, public sector, private
sector, and academia advise EPA on children's health issues in environmental policy. The work products
are letters to the Administrator that often outline gaps in literature or places where further research is
needed. Dr. Sathyanarayana went on to highlight some of these work products, and explain how they
relate to the work done by Children's Centers and PEHSUs.

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In 2013, CHPAC assembled a prenatal letter: "As requested, CHPAC provides EPA with recommendations
on research priorities to be included in the EPA ORD's children's health research roadmap that will
increase understanding of the scope of preconception and prenatal environmental exposures that can be
harmful, the communities most at risk, and effective exposure prevention strategies." This letter
highlights how EPA relies on CHPAC for high level questions. This letter was focused toward U.S. EPA ORD,
but the information can be extrapolated to the entire Agency. CHPAC also designated a list of priorities in
the 2013 letter: "Research on the health effects of prenatal and preconception exposures; research on
the interactions of environmental exposures, socioeconomic factors, and characteristics of sensitive
populations with poor birth outcomes, and incorporation of these types of data into mapping tools such
as EJView; research the effectiveness of commonly recommended exposure reduction measures; and
research on translation of scientific findings into actionable information for policy efforts as well as
individual prevention and reduction of exposures to harmful environmental chemicals."

In 2014, CHPAC produced a social determinants of health letter stating that "CHPAC sees a need for
continued research in the combined effect of stresses related to children's physical/social conditions and
chemical/immunological/pathogenic environmental hazards. CHPAC considers that the most practical
steps forward may include identifying a few, broad categories of stress, both social and environmental,
developing testable hypotheses for demonstrating the plausible synergistic effect of combined stresses."
Dr. Sathyanarayana emphasized the need to put physical and social conditions on the same level as
chemical and environmental hazards going forward. Although risk assessors want to use human data, Dr.
Sathyanarayana said it is not always presented in a usable way and risk assessors frequently use animal
data instead. Ways to make human epidemiologic research more useful to policy makers include modeling
exposure using continuous variables, showing actual exposure concentrations and ranges (i.e., not just
geometric means), and considering using the same endpoints as those in animal studies.

Many ongoing efforts have impressed Dr. Sathyanarayana. The Endocrine Society, comprise of clinicians
and research scientists, recently released a "Scientific Statement on Endocrine-disrupting chemicals
(EDCs)," proposing evidence-based guidelines on EDCs. Tracey Woodruff worked on the "Clinical Practice
& Policy: Navigation Guide," detailing one of the first systematic approaches to evaluating evidence
without bias and has been validated multiple times. Leo Trasande estimated burden and disease costs of
EDCs and other exposures. These are three different ways where policy and research and clinical work has
come together to move forward the agenda for children's environmental health. Irva Hertz-Picciotto's
project, "Targeting Environment and Neurodevelopmental Risks (TENDR)," brings together senior experts
and policymakers to put forth a grading mechanism and guidelines on how to consider environmental
exposures and neurodevelopmental outcomes.

Dr. Sathyanarayana shared needs she sees moving forward: a national surveillance network to document
disease and exposure-outcome relationships, better communication and harmonization across multiple
efforts, incorporation of environmental health into health care delivery, improved understanding of how
policy is made, and better translation to the public. Dr. Sathyanarayana concluded with some discussion
points: 1) How can we begin to look at specific non-traditional stressors such as non-chemical or hazards
outside the home in a more focused manner? 2) How can clinicians and researchers inform one another
in their combined goals? 3) How can all of us be more involved in translation of results and communication

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to the appropriate bodies: patients, public, government, and policymakers? She believes we are at the
tipping point of the intersection of policy, research, and clinical work, and there are many people working
in the policy arena that are ready to move forward in a profound way.

Preventing Childhood Leukemia: A Fruitful Partnership for Action
Catherine Metayer, M.D., Ph.D. | University of California, Berkeley

The UC Berkeley Center for Integrative Research on Childhood Leukemia and the Environment (CIRCLE)
started five years ago. The goal of their research is to understand why children develop leukemia and how
it can be prevented. The steps toward the answers include identifying chemicals and other risk factors,
identifying critical windows of exposures, measuring risk in vulnerable populations, describing underlying
mechanisms, assessing the influence of genetic make-up, and disseminating and translating their findings
into preventative measures to limit exposure. The Western States PEHSU representatives are true
coinvestigators with the Children's Center. Not only they are actively involved in translating research and
coordinating outreach, but they are fully engaged in the research activities from the study onset and every
subsequent stage. Dr. Catherine Metayer meets with her PEHSU colleague, Mark Miller, on a monthly
basis to discuss progress made and opportunities for collaboration. Below are few examples.

Working with the PEHSUs brought an outside perspective to the current trend and disparity in childhood
leukemia incidence, which helped Dr. Metayer and her Children's Center strengthen their mission to
bridge research to prevention. Indeed, over the past 30 years, there have been increasing incidence rates
of childhood leukemia, especially in Hispanic children. African American children have the lowest risk in
the early years, but the trend rises over time. Such increase is likely due to change in exposures, either
alone and or in combination with genetic susceptibility. The Children's Centers and PEHSUs have
partnered with the California Cancer Registry to conduct a detailed descriptive analysis on childhood
leukemia trend in California, which exemplifies real collaboration. Dr. Metayer then discussed the risk
factors for leukemia in which they are interested such as smoking, paints, solvents, and pesticides. Most
of them are known carcinogens in adults, and CIRCLE has focused on assessing their impact on children.
The PEHSUs provided insight into some other factors not looked at before, including social stressors,
prompting the Children's Center to edit their data collection questionnaire to include indicators of stress.

Dr. Metayer emphasized that translation and dissemination of their findings was a large component of
their work. Mark Miller from the PEHSUs developed the "Story of Health" e-book, which prompted the
Children's Center to think about where they are and what they want the key message of their research to
be. This process was fully integrated in ongoing discussion for what they want to do next. They expanded
access to and contact with hospitals to present their work to physicians, and also conducted a survey for
health care providers to understand their knowledge, and learn what health professional think are the
causes of leukemia. The results were published in the Journal of Pediatric Hematology/Oncology.
Physicians for Social Responsibility invited them to write a short piece on the causes of leukemia, which
was a short introduction to their research that has since evolved. Indeed, Dr. Metayer was invited to be
part of a CDC workshop to understand early exposure and development of cancer later in life, which was
an opportunity to work with Dr. Miller to write a paper on preventable factors for childhood leukemia.

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The PEHSUs helped enlarge the vision of the Children's Center by sponsoring activities around climate
change, which does not impact current research but helps them become part of the larger effort to
improve children's environmental health.

Dr. Metayer concluded that the relationship between PEHSUs and Children's Centers is reciprocal, sharing
expertise for both research and translation activities. Many chemicals found to increase the risk of
childhood leukemia are also known to increase the risk of other diseases in children. The PEHSUs are part
of a larger network and broad vision to address cumulative impact of these exposures, which is why it is
important to continue working together on these challenges.

Session 11 Questions, Answers, and Comments

The Q&A session began with a question from the moderator, Kim Gray, of NIEHS. She discussed how the
relationships between Children's Centers and PEHSUs are organic. There is no requirement making them
work together, but they find themselves working together quite frequently. As there is currently no official
process, she asked the PEHSU representatives in the room if they had any ideas on some collaborative
efforts they should focus on together. Bruce Lanphear of Simon Fraser University responded that when
he worked in Cincinnati, they were adopted by the Chicago PEHSU. They started reporting biomarkers
back to families, a lot of which was done without funding as it was the right thing to do. They sent out
letters, hosted a hotline, and the PEHSU representative served as a point person to answer questions
about exposure levels. This collaboration worked out very well. Dr. Sathyanarayana said that one thing
she sees is that the Children's Centers do a lot of research, and sometimes have an adverse health
outcome in their cohort they did not expect to see (i.e., it is a statistical outlier, but means a lot clinically).
One example in Bruce Lanphear's cohort was a significant abnormal neonatal neurobehavioral exam,
which turned in to a published case study about BPA exposure. The Children's Centers can keep data that
the PEHSU clinicians know what to do with, ensuring that the information gets translated and not buried
in the research world.

An affiliate of the Children's Center at the University of Illinois at Urbana-Champaign said it was helpful
for PEHSU members to be on advisory boards of Children's Centers to assist with crafting messaging.
Frontline health care providers are not in marketing, but they do communicate one-on-one with patients.
It is helpful to interact with Children's Centers about their messaging for the findings. She wondered if the
Children's Centers should require a PEHSU member, and was informed they were required to have a
pediatric specialist of their choosing. Although it is recommended they partner with a PEHSU, it is not a
formal requirement. Dr. Sathyanarayana felt that communication is the first step to building relationships
between PEHSUs and Children's Centers. A good example is when the arsenic findings on apple juice and
rice came out in the media. If there was a PEHSU member on the advisory board, they could have been
preemptive against concerned calls from parents or put out a one-page clinical handout for clinicians and
providers. Regarding the arsenic issue, Dr. Jennifer Lowry, with the Region 7 PEHSU and the Chair of the
Council for Environmental Health for AAP, added that when the information went out, there was mass
coverage and response in the media. PEHSUs are very good at responding quickly, and if there had been
some warning from the Children's Centers, they could have preempted some of the panic and confusion

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that occurred. Much of the Children's Centers' research is published in journals not necessarily read by
OBGYNs, pediatricians, or family practice clinicians. If someone is concerned about an illness or exposure,
they will go to Google, not PubMed. She feels there needs to be a dialogue on how we can accurately get
Children's Centers' research from the scientific journals in which it is published to the people that actually
need it. Dr. Metayer thought that was a good point. Recently, she has been involved in showing research
at society meetings, which has been underutilized up to now. She thinks there is a need to speak to a
broader audience of health providers. Research could be published in journals aimed at the target
audience, but Dr. Lowry warned that the target audience will not necessarily understand how to translate
the research to their practice, which could lead to misunderstandings and miscommunication. A
commentary or other co-effort to send them digestible and practical information would be helpful.

An affiliate of the Region 1 PEHSU said the formal collaboration between PEHSUs and CEHCs is especially
important when data are about to go out and context needs to be given to providers; however, funding
for PEHSUs is often limited. Dr. Metayer agreed that the resources for PEHSUs are give-and-take, and they
need resources to collaborate with the Children's Centers. The next questioner said that the discussion
has been focused on individual partnerships between one PEHSU and one Children's Center. He wondered
how they can maximize the information exchange in the wider network. Dr. Kim Gray said there is a
Children's Centers meeting every month if there is something to discuss. Dr. Sathyanarayana said that
something that cannot be ignored is that some of this is a higher-level funding discussion, asking whether
we want the two to combine and work together in a mandated way. Dr. Gray explained that the Children's
Centers have been built since 1998 and have a very strong infrastructure. They need to work within the
built structure and current RFA and embrace the collaboration. Dr. Lowry pointed out that the Children's
Centers get a lot more money. Dr. Gray responded that the mission of NIH is biomedical research.
Children's Centers have three research projects and are running very thin, similar to the PEHSUs, so they
need to work together. Dr. Metayer said something they have been discussing in their group is looking for
additional side funding for outreach and translation, because it is a great platform for targeted projects.
Dr. Gray agreed, saying leveraging the two programs together is a potential new idea to think about for a
program. The final question came from an affiliate of the Southeast PEHSU and Break the Cycle program,
who said that a listing of subject matter experts that PEHSUs and Children's Centers could use as resources
to answer questions would be helpful. Dr. Gray said NIEHS funds over $115 million in children's
environmental health, so they have subject matter expertise outside the Children's Centers available on
the NIEHS website. She agreed that would be a very good tool to potentially add to the Children's Centers'
websites.

Session 12 - Keynote

Moderated by Frederica Perera, Ph.D., M.P.H. | Columbia University

Adam Smith and the Business Case for Children's Environmental Health
Leonardo Trasande, IVi.D. | New York University

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Dr. Leonardo Trasande began his presentation by referencing Adam Smith, a Scottish philosopher, best
known for conducting the first modern work in economics, outlining the conditions for a properly
functioning market economy. Dr. Trasande argued that Adam Smith would be passionate about children's
environmental health, because environmental hazards produce market failures that are costly to society.
The two sets of market inefficiencies introduced by environmental hazards are externalities and
information asymmetry in economic and business transactions.

In a typical business transaction, there is an expectation that goods and money will be exchanged without
external effects on those not involved in the transaction. An externality is a "spill-over" effect, with one
person's activity influencing the utility of others outside of that activity. Point-source air pollution is a
good example. Electricity producers emit PM and other respiratory irritants into the air, which results in
children developing respiratory illnesses. Children are not participating in the economic transaction but
are experiencing adverse health effects as a result. Ultimately society pays for this in the form of additional
health care costs (hospitalization, emergency room, prescription drugs) and other downstream costs from
loss of work, school, and productivity. This results in an over-production of electricity that is not accounted
for in the transaction. The cost is not appropriately perceived by the producer, and therefore, electricity
is produced above the societally optimal amount at a cost below the societally optimal amount. This is
referred to as deadweight loss; a cost to society we all bear as a result of an activity that should not occur.

The second problem of information asymmetry relates to food contamination. The label tells you the
nutritional value when you buy a product, but it does not include the finer details of the product. When
you want to compare two different products, you might not have all the information necessary to make
the optimal selection. Ideally, you know everything that you are getting insofar as it impacts your well-
being, which, in theory, drives your decision-making in pricing things differentially. At a theoretical level,
you attach an implicit value that might be greater or less than the product's true value, depending on your
current state of health. "Lemons competition" refers to a situation in which one side of the transaction
has more information than the other. The purchaser then has an uncertainty that results in erring on the
side of caution, which brings down the value of certain goods out of fear of contamination and drives
other goods out of the market. Two sets of problems exist: the producer has more information than the
consumer, and the risk uncertainty incurred as a result leads to mispricing of products compared to the
societally optimal amount. In the context of food contamination, organic labeling is a partial solution as it
levels the playing field and pricing mechanisms. Complications remain, however, regarding the complexity
of that communication. There can still be incomplete information about what is in organic food, and there
are controversies over what can be included in organic food. As long as there is still an unwillingness to
disclose ingredients in a food item, a partial amount of that problem will still cause market dysfunction.

Dr. Trasande discussed the estimated costs to society of these market inefficiencies, which are largely
unknown. This is partly due to the current regulatory framework set up by the Toxic Substances Control
Act of 1976, which employs an "innocent until proverbially guilty" mindset to chemicals, in that premarket
testing of chemicals is not required. Epidemiological and toxicological studies investigate exposure and
response relationships. Latencies to disease, many potential confounders to outcomes, issues with
reproducibility of studies and consistency of data, and uncertainty about dose-response relationships and
thresholds lead to policy debates about what the effects are, and what to do about them at a societal

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level. In the context of uncertainty, subclinical effects that might exist from multiple factors that cause
chronic disease delay acting on information, which has a cost. The amount of this cost remains equally
uncertain, because epidemiologic and toxicological research is needed to quantify the relationship
between exposure and response. The best and most recent estimates are that the costs of environmental
hazards to children are quite substantial. In 2011, Trasande and Liu looked at conditions for which
evidence was greatest for environmental causation, including lead poisoning, intellectual disability, and
ADHD. Their best estimate of aggregate costs of environmentally mediated diseases in U.S. children in
2008 was $76.6 billion, roughly three percent of U.S. health care costs. Bartlett and Trasande did a follow-
up analysis in 2014 looking at environmentally attributable costs of lead exposure, methylmercury
exposure, developmental disabilities, asthma, and cancer in the European Union (EU), and found it to be
$70.9 billion in 2008, roughly 0.48 percent of the EU's gross domestic product (GDP). In 2013, Attina and
Trasande looked at the costs of lead exposure in low- and middle-income countries and found there was
a $992 billion annual cost from lost productivity resulting from IQ losses. The costs in developing countries
are even greater than in the United States and Europe, perhaps speaking to the need to allocate resources
for prevention differentially. The other problem is the economic impact of environmental injustice. People
who bear the brunt of exposure often have the lowest income, thus environmental hazards magnify social
inequality.

Faced with these market failures from environmental hazards, Dr. Trasande asked what would Adam
Smith do? In theory, Adam Smith would potentially sign off on government intervention. Although the
government might improve the situation by correcting the mechanism, it can also worsen the situation.
When government intervention is presented as a solution, there is resistance in part due to potential
market inefficiencies. This argument was made during the Affordable Healthcare Act debate. There are
three examples of government intervention as an economic solution in environmental health. The first
example is phasing out lead in gasoline, which is the landmark example of the economic benefits that can
result from corrective government action and environmental prevention. The phasing out of lead in gas
was a benefit for children and for facilitating the ongoing use of catalytic converters in cars. It was due to
National Health and Nutrition Examination Survey (NHANES) data on lock-step decreases in children's
blood levels that stopped the reinstitution of lead in gas. This was a wise health and economic decision.
Grosse et al. did a series of analyses in 2002 showing that the 15 microgram/deciliter drop off in blood
lead led to a four to seven point increase in IQ. Across society that magnifies into billions of dollars, with
every IQ point resulting in a roughly two percent increase in a child's lifetime economic productivity.
Across the population, on average one IQ point is worth $20,000, so multiplying that by four IQ points by
roughly four million births per year leads to a very large number; approximately $219 billion of economic
stimulus simply by phasing out lead in gasoline. The global benefits are even larger. The best estimate is
approximately $2.45 trillion per year, or four percent of global GDP. This serves as a great example of how
inefficiencies can be reversed and yield huge economic benefits.

Another option Adam Smith might suggest is a Pigovian tax, which is a tax on producers equal to the
amount of the economic damage suffered by those who experience the externalities of the activity.
Ideally, this would ensure producers perceive the economic inefficiency their actions create, and change
their behavior. Hypothetically speaking, there are two issues with this strategy. One is that the children
who have suffered the externality would need to receive the payout from the tax, but taxes go to a general

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revenue. The other issue is accurately quantifying the exact amount of damage at the individual level and
aggregating to the population level to place the right amount of economic cost on the producers. On a
theoretical level, this is hard to do.

The third government intervention is the "polluter pays provision/' which is a penalty on a polluter
equivalent to the economic harm suffered. In some ways this is the prime premise of the Superfund
program. It is difficult to actualize in part due to a long latency in identifying a problem, and the potential
lawsuits brought by EPA against companies that are now defunct. It is not possible to ensure the financial
transaction to compensate for damages inflicted on society by toxic environmental exposure occurs. In
general, regulation is the most straightforward way to correct market inefficiencies.

Dr. Trasande then explored a case study involving EDCs, which are a broad category of widely used
chemicals with limited epidemiological evidence linking them to health conditions. Prevention of EDC-
mediated disease will occur by phasing out their use, but there is a trade-off between the cost of safer
alternatives and the economic benefits of prevention. In Europe, in 2009 and 2011, in the aftermath of
Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) legislation, there was an
effort to identify principles for regulating pesticides and biocides with endocrine disrupting properties
that might have harmful health and environmental effects. This process has been long and arduous. A risk
assessment is being pursued to identify the proper criteria for identifying and then eliminating EDCs. At
the time, there were no data quantifying the economic benefits of regulating EDCs insofar as they improve
health. Trasande et al. pursued a series of analyses to quantify a range of health and economic costs that
can be reasonably attributed to EDC exposures in the European Union.

Before explaining the analysis, Dr. Trasande provided some background information on the principles one
should use in identifying causation, set forth by Sir Austin Bradford Hill. The only principle required for
causality is the temporal relationship, that is, exposure must happen before the effect. There are a series
of other optional, but still important, criteria to determine whether an exposure-outcome relationship is
causal: consistency, substantial effect size, dose-response relationship, biological plausibility, effect
specificity, coherence with existing knowledge, experimental evidence, and consideration of alternate
explanations. When you look at the literature to see how principles have been applied, causation is usually
binary (i.e., yes or no). Current practice, however does not follow what Sir Austin Bradford Hill proposed:
"I do not believe...that we can usefully lay down some hard-and-fast rules of evidence that must be obeyed
before we accept cause and effect." More recently, the Intergovernmental Panel on Climate Change (IPCC)
embraced the probability of causation, and developed a series of criteria for grading probability of
causation. Trasande et al. were able to leverage this framework for thinking about the probability of
causation in the context of the European Union EDC project. They also took advantage of the GRADE
(Grading of Recommendations Assessment, Development and Evaluation) scheme, WHO's framework for
evaluating and ranking evidence by quality. In addition to study design (cohort, cross-sectional,
randomized controlled trial, etc.), there are other items that can affect rank, such as study limitations,
uncertainty, and bias. They also adapted the Danish Environmental Protection Agency criteria for
toxicological evidence. By adapting the IPCC criteria to integrate the toxicological and epidemiological
evidence, they were able to create working groups to evaluate the types of evidence available and derive
a probability of causation.

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During a two-day workshop in Spring 2014, five expert panels identified conditions in which the evidence
was strongest for causation and developed ranges for fractions of disease burden that could be attributed
to EDCs. To quantify attribution, they prioritized dose-response relationships from the epidemiologic
literature and used peer-reviewed cost-of-illness data whenever possible. Much of the evidence for
developmental neurotoxicity, organophosphates, and brominated flame retardants is rated highly due to
strong toxicological evidence of thyroid effects and consistent dose-response relationships in longitudinal
birth cohorts. This led to high probability of causation for those relationships. The evidence for the
obesogenicity of phthalates was rated as more moderate. In addition, multiple male reproductive effects
were identified with moderate probability of causation, and neurobehavioral outcomes such as autism
and ADHD had low or moderate probabilities.

Trasande et al. 2015 identified substantial costs due to decreased economic productivity from lost IQ
points from exposure to pesticides: €124 billion lost earning potential and an additional €21.4 billion lost
from increased incidences of intellectual disability. There was also modest attribution with persistent
pesticides totaling approximately €850 million. For phthalates, they found substantial costs due to early
mortality from cardiovascular health outcomes, primarily in adult males: 24,800 additional deaths among
55-64 year old men, totaling €7.96 billion in lost economic productivity. They also identified a cost of
€4.71 billion from 618,000 additional assisted reproductive technology procedures in men, and
substantial attributions to obesity and obesity-related diseases (e.g., diabetes). Flame retardants had
moderate disease burdens in the form of lost IQ points, totaling €6.4 billion in lost earning potential, and
they were also associated with new cases of testicular cancer and undescended testis. Additional cases of
autism, ADHD, and childhood obesity had moderate associations.

Dr. Trasande explained how all of the burden of disease cost numbers assume certainty; at this point
probability of causation is introduced. The team conducted Monte Carlo analyses to model potential costs
and the cumulative probability. On average, they calculated an estimated €157 billion, with the possibility
that the cost could be as high as €270 billion. They broke down the €157 billion estimate and found that
pesticides were the most costly chemical type (accounting for €120 billion of the total cost) and
neurological impacts were the most costly health effect (accounting for €132 billion of the total cost). Dr.
Trasande explained that the €157 billion is likely a substantial underestimate of the true cost of EDC
exposure. They only considered less than five percent of EDCs, many health conditions were not
examined, and the numbers did not consider all of the costs associated with these chronic conditions.
Given that a similarly large burden of disease may be attributable to EDCs in the United States, costs are
likely to be the same, if not higher. For example, costs of flame retardant use may be higher in the United
States, as use is more stringently limited in Europe. Levels of phthalates (DEHP), however, have decreased
in the past decade and thus might have lower costs of attributable disease. In general, these findings
support the need for an international strategic approach to chemicals management.

Dr. Trasande closed with an example in the United States. They conducted an analysis of the health costs
that can be attributed to BPA, recognizing uncertainty and all the exposure-outcome responses to date,
due to U.S. FDA's decision to not phase out BPA in aluminum cans. The cost of oleoresin, a BPA alternative
(leaving aside the actual safety of oleoresin), is $0,022 per can, or about $2.2 billion annually. Trasande et
al. did a series of cost-of-illness methods for childhood obesity and adult coronary heart diseases, using

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exposure data from NHANES. They also modeled a counterfactual scenario using intervention studies that
quantified decrements in BPA associated with the removal of BPA in food sources. The best-case scenario
costs of BPA-associated childhood obesity was $748 million, and $987 million for adult coronary heart
disease. The counterfactual model documented a benefit on the order of $1.9 billion annually. Compared
to the $2.2 billion it would cost to replace BPA in aluminum cans, it is a close call, and potentially indicates
there could still be more costs than benefits associated with replacing BPA. A sensitivity analysis of the
benefits, however, suggests they could actually be 6-fold higher ($13.8 billion annually) than the
associated costs.

Dr. Trasande summarized the key points: environmentally mediated diseases are costly, create market
inefficiencies, and prevention methods can result in large economic benefits. Ultimately there is a strong
business case for proactively intervening. He also emphasized that it is time for the field to accept
uncertainty in exposure-outcome relationships to be able to inform policymakers. If the data are not at
the table, recognizing the caveats raised about the probability of causation, there will never be an
educated decision by policymakers on whether or not to intervene in chemical regulation.

Session 12 Questions, Answers, and Comments

The moderator, Dr. Frederica Perera, asked if Dr. Trasande had considered life-course benefits. He
responded that all the analyses he described did consider life-course benefits wherever possible. In fact,
the research on the benefits of childhood obesity prevention included discounting for longer-term
benefits that aggregate over time, for example, adjusted expected life years. The next questioner said she
appreciated how difficult this research is, and why for the business case, it makes sense to focus on
potential losses as a result of IQ points. She pointed out that there are also real losses associated with
neurodevelopmental disabilities that do not necessarily manifest in IQ decrements (e.g., cost to medical
care providers, lost parent time at work, pharmaceuticals not covered by insurance), and asked to what
extent they could account for them. Dr. Trasande agreed and said the reality is that they do their best to
document what they cannot quantify. As long as they underestimate and the costs are large, that provides
the fuel for the fire in decision-making in health and environmental policy. If these analyses are not
grounded in the most rigorous economic, environmental, biomarker, and epidemiological data, the
economic estimates will be dead on arrival from a policymaking perspective.

Bruce Lanphear, Simon Fraser University, said he saw online that if you take into account all the
externalities, relatively few of the Fortune 500 companies would be profitable. He asked if this was true.
Dr. Trasande said it was not correct, because when those externalities are corrected, there are ultimately
some other entities that produce more appropriately and experience gains. There are internally winners
and losers. In the current scenario the winners are winning at the cost of others, whereas winners in the
scenario of corrective prevention are the companies that are proactively identifying safer alternatives,
intervening, and recouping those economic benefits.

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Conclusions

Nica Louie congratulated the participants of the 2015 NIEHS/EPA Children's Centers Meeting. She thanked
and honored everyone who worked to put the meeting together, including the planning Committee,
speakers, and ICF team. She said she hoped they had met the expectations of everyone who participated.
She remarked there was enough information presented in a variety of ways that can be helpful to all as
they work toward helping and protecting children, which is why they do what they do. Ms. Louie said she
was grateful and thankful for Children's Health month and all the events that occurred.

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Appendix A - Agenda

2015 NIEHS/EPA Children's Centers Annual Meeting

October 29-30, 2015

Day 1: Thursday, October 29, 201

7:30-8:30 a.m.

8:30-9:30 a.m.

9:30-10:15 a.m.

10:15-10:30 a.nr

10:30-11:00 a.rr

11:00-12:30 p.m

EGISTRATION

Session 1 - Welcome and Introduction

Moderated by James H.Johnson, Ph.D., M.S. | Director, National Center for Environmental

Research, U.S. EPA

The Role of NIEHS in Supporting Children's Environmental Health

Linda Birnbaum, Ph.D. | Director, National Institutes for Environmental Health Sciences

CDC/ATSDR's Role in Children's Environmental Health

Patrick Breysse, Ph.D. | Director, National Center for Environmental Health/Agency for Toxic

Substances and Disease Registry, Centers for Disease Control

Children's Environmental Health: From Knowledge to Action

Ruth Etzel, M.D., Ph.D. | Director, Office of Children's Health Protection, U.S. EPA

Session 2 - Keynote

Moderated by Kari Nadeau, M.D., Ph.D. | Stanford University

This session will provide a holistic, conceptual framework and describe programmatic
interventions designed to help minimize toxic exposures and mitigate related risks
throughout early stages of life.

America Healing: A 21st Century Imperative

Gail Christopher, D.N. | Vice President of Policy and Senior Advisor, W.K. Kellogg Foundation

Session 3

The future of children's environmental health is a public health issue. Healthy children
lead to healthy adults, and healthy adults lead to a prosperous, healthy society. This
session will highlight successes of the Children's Environmental Health and Disease
Prevention Research Centers, and of the collaborative efforts between EPA and NIEHS.

Protecting Children's Health in the Future: Adapting to a Changing World

Thomas Burke, Ph.D. | Science Advisor, U.S. EPA

BREAK

Session 4 - Social Determinants of Health

Moderated by Andrew Geller, Ph.D., M.A. | Deputy National Program Director, Sustainable

and Healthy Communities Research Program, U.S. EPA

Children who grow up in circumstances of social and economic disadvantage are at
greater risk for exposure to adverse environmental factors and are more likely to suffer
consequent adverse health and developmental outcomes. This session will address the

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role of the environment in health disparities, focusing on where we live, learn and work
and the contribution of pollutants and allergens.

Asthma Disparities and the Indoor Environment

Greg Diette, M.D. | Johns Hopkins University

Psychological Stress & Perinatal Programming of Chronic Disease

Rosalind Wright, M.D., M.P.H. | Mount Sinai Hospital

Students Break the Cycle of Environmental Health Disparities

Leslie Rubin, M.D. | Emory University

CalEnviroScreen and Potentially Preventable Childhood Morbidity in California's Central
Valley

Emanuel Alcala, M.A. | Central Valley Health Policy Institute

12:30-2:00 p.m. LUNCH

1:00-1:50 p.m. Brownbag Lunch Session - Community Outreach and Translation Core
Wilson/Roosevelt Room

Kelly Widener | Communications Director, National Center for Environmental Research, U.S.
EPA

Virginia Guidry, Ph.D. | Office of Communications and Public Liaison, National Institute of
Environmental Health Sciences

2:00-2:30 p.m. Session 5 - Keynote

Moderated by Michael Hatcher, Ph.D. | Chief Environmental Health Branch, Agency for
Toxic Substances and Disease Registry, CDC

This session will provide examples of two component models of the life course
perspective - Early Programming and Cumulative Pathways - and discuss implications for
children's environmental health.

The Life Course Perspective and Children's Environmental Health

Michael Lu, M.D., M.S., M.P.H. | Heath Resources and Services Administration

2:30-4:00 p.m. Session 6 - Neurodevelopmental Disorders

Moderated by Susan Schantz, Ph.D. | University of Illinois at Urbana-Champaign

There has been a tremendous increase in understanding of early brain development and
how this can be impacted by environmental influences. Evidence of developmental
neurotoxicants will be presented, using case examples. This session ends with a panel
discussion that identifies new opportunities for application as well as discussion on how
these novel methods will impact clinical practice.

Lessons Learned From the New Bedford Cohort Study

Susan Korrick, M.D. | Harvard University

The Long-Term, Brain-Based Effects of Prenatal Exposure to Two Environmental
Neurotoxicants

Bradley S. Peterson, M.D. | Children's Hospital Los Angeles

It's about 4 Million Brains a Year - Toxic Chemicals and the In Utero Environment

Tracey Woodruff, Ph.D., M.P.H. | University of California, San Francisco

From Science to Policy: Targeting Environment and Neuro-Developmental Risks (Project
TENDR)

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Irva Hertz-Picciotto, Ph.D., M.A., M.P.H. | University of California, Davis

4:00-4:30 p.m. BREAK

4:30-5:30 p.m. Session 7 - Concurrent Sessions

•	Session 7a - Obesity (Constitution C)

•	Session 7b - Exposome (Constitution D)

•	Session 7c - Reproductive Health (Constitution E)

Session 7a - Obesity (Constitution C)

Moderated by Dana Dolinoy, Ph.D. | University of Michigan

Emerging evidence indicates that environmental exposures may contribute to the
development of obesity. This session aims to provide an overview of environmental
factors that may contribute to childhood obesity, as well as examples of innovative
collaborations working towards addressing the role of the environment in childhood
obesity. As the evidence grows so too has the outreach and education tools for use with
diverse audiences including the general public, community based organizations, health
care professionals, public health officials, policy makers and others. This session will also
provide examples of publicly available educational outreach tools.

The Contribution of Environmental Exposures to Childhood Obesity

Rob McConnell, M.D. | University of Southern California

Early Toxicant Exposures and Development of Child Obesity: Evidence and Gaps from

Recent Research

Karen Peterson, Sc. D. | University of Michigan

Environmental Health and Childhood Obesity: From Research to Action

Maida Galvez, M.D., M.P.H. | Mount Sinai Hospital

Session 7b - Exposome (Constitution D)

Moderated by Claudia Thompson, Ph.D. | National Institute of Environmental Health
Sciences

The exposome encompasses the totality of human environmental exposures, and
complements the genome. Although at this stage it may not be possible to measure or
model the full exposome, some recent projects have made first attempts. This session will
provide examples of how the exposome may affect causal pathways in childhood disease,
and present potential platforms to initiate sequencing of the human exposome.

Using a Risk Assessment Framework to Integrate Epigenetic Outcomes with Exposome
Assessment for Neurodevelopment

Elaine M. Faustman, Ph.D. | University of Washington

High-Resolution Metabolomics for Sequencing the Exposome

Dean P. Jones, Ph.D. | Emory University

Environmental Exposures in Early Life Influence Childhood Leukemia

Stephen M. Rappaport, Ph.D. | University of California, Berkeley

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Session 7c- Reproductive Health (Constitution E)

Moderated by Tracey Woodruff, Ph.D., M.P.H. | University of California, San Francisco
New issues in reproductive health with reference to environmental exposures will be
discussed. Evidence from recent research will be presented to suggest potential
relationships between early-life exposures to endocrine disrupting chemicals and adverse
reproductive health outcomes.

Updates on Environmental Effects on Reproductive Health

Marya Zlatnik, M.D. | University of California, San Francisco

Impacts of Early-life Exposure to Endocrine Disrupting Chemicals on Puberty

John Meeker, Sc.D., C.I.H. | University of Michigan

The Pros and Cons of Testing Patients for Toxin Exposures

Susan Buchanan, M.D., M.P.H. | University of Illinois at Chicago

5:30-7:00 p.m.

Poster Session

Wilson/Roosevelt/Cabin John/Arlington Rooms



Day 2: Friday, October 30, 2015

7:30-8:30 a.m.

REGISTRATION

7:30-8:30 a.m.

Coffee* with Dr. Sally Darney, Editor-in-Chief, Environmental Health Perspectives

Wilson/Roosevelt Room

*Please come with your morning beverage

8:30-9:30 a.m.

Session 8 - Keynote

Moderated by Margaret Karagas, Ph.D. | Dartmouth College

The impact of toxins are usually subtle for an individual child, but they can be substantial
at the population level. This session will provide an overview of the population impact of
toxins on children's health to set the stage for dialogue about ways to articulate the
impact and importance of toxins on child health.

Little Things Matter: The Impact of Toxins on Children's Health

Bruce Lanphear, M.D., M.P.H. | Simon Fraser University

9:30-10:20 a.m.

Session 9a - Community Outreach and Research Translation, Part I

Moderated by Catherine Karr, Ph.D., M.D., M.S. | University of Washington

A long-term goal of the Children's Environmental Health Centers is promoting translation
of basic research findings into intervention and prevention methods to prevent adverse
health outcomes. The Children's Centers provide credible and high impact environmental
health research results in ways that are relevant and understandable to the general
public. Examples from Children's Centers researchers and the National Pediatric
Environmental Health Specialty Unit Program will demonstrate opportunities to ensure
children's environmental health is efficiently, effectively, and meaningfully transmitted to
clinical and public health practitioners.

Environmental Health Perspectives (EHP): Your Partner in Research Translation

Sally Darney, Ph.D. | Editor-in-Chief Environmental Health Perspectives

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Why Are Doctors Talking Toxics?

Patrice Sutton, M.P. H. | University of California, San Francisco

Do No Environmental Health Harm - An Updated Oath

Jennifer Lowry, M.D. | Children's Mercy Hospital

Simplifying the Complicated: Leveraging Digital Media for More Effective Community
Engagement and Research Translation

Carolyn Murray, M.D., M.P.H. | Dartmouth College

10:20-10:50 a.m. BREAK

10:50-11:50 a.m. Session 9b - Community Outreach and Research Translation, Part II

Moderated by Catherine Karr, Ph.D., M.D., M.S. | University of Washington

Build It and Will They Come? Lessons Learned from A Story of Health e-Book

Mark Miller, M.D., M.P.H. | University of California, San Francisco

#duetoepigenetics #whatdoesthatmean #mustbevoodooscience

Susan Murphy, Ph.D. | Duke University

11:50-1:15 p.m. LUNCH

12:20-1:00 p.m. Brownbag Lunch Session with Linda Birnbaum and Ruth Etzel
Wilson/Roosevelt Room

1:15-2:45 p.m. Session 10 - The Pediatric Environmental Health Specialty Units Present: Emerging

Topics in Children's Health

Moderated by Carl Baum, M.D., M.Sc. | Yale University

Children are exposed to environmental factors that may affect their health and
development. This session allows the PEHSUs to present on lesser known and emerging
environmental issues. The goal is to present the state of the science on questions raised
by parents and other caregivers and stimulate discussion about the science and practical
applications of the research with the presenters in a concluding panel. The session is
organized into five-minute presentations on each topic.

A Blueprint for Protecting Children's Environmental Health: An Urgent Call to Action

Nsedu Witherspoon, M.P.H. | Children's Environmental Health Network

Potential Health Hazards of Increasing Cell Phone Use

Laura Anderko, PhD., M.S., R.N. | Georgetown University

Studies of Children's Exposure to Chemicals on Artificial Turf Fields

Gary Ginsberg, Ph.D. | Connecticut Department of Public Health

Not So Pretty - Endocrine Disrupting Chemicals in Cosmetics and Perfumes

Katie Huffling, R.N., M.S., C.N.M. | Alliance of Nurses for Healthy Environments

Maternal Exposure to High Levels of Electromagnetic Fields (EMFs) During Pregnancy and

the Long-Term Health Impact on Their Offspring

De-Kun Li, M.D., Ph.D., M.P.H. | Kaiser Permanente Division of Research

Trends in Consumption of Artificial Sweeteners and the Metabolic Effects

Allison Sylvetsky, Ph.D. | George Washington University

Children's Health Impacts of Climate Change

Perry Sheffield, M.D. | Mount Sinai Hospital

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Environmental Drivers of Diarrheal Disease among Children in Botswana

Kathleen Alexander, Ph.D., D.V.M. | Virginia Polytechnic Institute and State University

2:45-3:45 p.m. Session 11 - Next Steps for Collaboration between the Children's Environmental

Health Centers (CEHCs) and the Pediatric Environmental Health Specialty Units

(PEHSUs)

Moderated by Kimberly Gray, Ph.D. | National Institute of Environmental Health Sciences
This session will highlight how effective collaborations that capitalize on research and
clinical expertise can lead to important gains for the CEHCs, PEHSUs, and the
environmental health field. The presentation will give some concrete examples of current
successful partnerships and ideas for future partnerships. We will then open the session
to audience questions and a panel discussion.

Overview of Pediatric Environmental Health Specialty Units (PEHSUs)

Ruth Etzel, M.D., Ph.D. | Director, Office of Children's Health Protection, U.S. EPA

How PEHSUs and CEHCs Can Inform Children's Environmental Health Policy

Sheela Sathyanarayana, M.D., M.P.H. | University of Washington

Preventing Childhood Leukemia: A Fruitful Partnership for Action

Catherine Metayer, M.D., Ph.D. | University of California, Berkeley

3:45-4:30 p.m. Session 12 - Keynote

Moderated by Frederica Perera, Ph.D., M.P.H. | Columbia University

While much attention is given to conducting studies of early life environmental exposures
in the laboratory and humans, less focus is placed on the costs of failing to protect
children. This session will present the economic benefits for proactive regulations that
protect children, and the business case for children's environmental health.

Adam Smith and the Business Case for Children's Environmental Health

Leonardo Trasande, M.D. | New York University

4:30 p.m.	Closing Remarks and Adjourn

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Appendix B - Speaker Biographies
2015 NIEHS/EPA Children's Centers Annual Meeting

Thomas Burke | U.S. EPA

Session 3

Dr. Thomas Burke is the Deputy Assistant Administrator of EPA's ORD as well as EPA's Science Advisor.
Before coming to EPA, Dr. Burke served as the Jacob I. and Irene B. Fabrikant Professor and Chair in Health,
Risk and Society and the Associate Dean for Public Health Practice and Training at the Johns Hopkins
Bloomberg School of Public Health. He was also a Professor in the Department of Health Policy and
Management, with joint appointments in the Department of Environmental Health Sciences and the
School of Medicine Department of Oncology. Additionally, he was the founder of and served as the
Director of the Johns Hopkins Risk Sciences and Public Policy Institute. His research includes the
development of new approaches to environmental health risk assessment and environmental health
surveillance, and their applications to environmental health policy.

Before his time at Johns Hopkins, Dr. Burke was Deputy Commissioner of Health for the State of New
Jersey and Director of the Office of Science and Research in the New Jersey Department of Environmental
Protection. In New Jersey, he directed initiatives that influenced the development of national programs,
such as Superfund, the Safe Drinking Water Act, and the Toxics Release Inventory.

Dr. Burke also served on EPA's Science Advisory Board, as well as advisory boards for the Centers for
Disease Control and Prevention, and on various committees for the National Academy of Sciences (NAS).
Dr. Burke chaired the NAS committee that wrote the "Science and Decisions: Advancing Risk Assessment"
report. The report, commonly known as the Silver Book, examines some of the greatest challenges to the
country's assessment, management and communication of environmental risks.

Dr. Burke received his Ph.D. in epidemiology from the University of Pennsylvania, his M.P.H. from the
University of Texas, and his B.S. from Saint Peter's College.

Linda Birnbaum | National Institute of Environmental Health Sciences

Session 1 - Welcome and Introduction

Dr. Linda Birnbaum became the Director of NIEHS and of the National Toxicology Program (NTP) in January
2009. In these roles, she oversees federal funding for biomedical research to discover how the
environment influences human health and disease. Several advisory boards and councils provide Dr.
Birnbaum and NIEHS/ NTP staff with input to accomplish this large task. She is the first toxicologist and
the first woman to lead the NIEHS/NTP. She has spent most of her career as a federal scientist. Dr.
Birnbaum also serves as an Adjunct Professor in the Gillings School of Global Public Health, in the
Department of Environmental Sciences and Engineering at the University of North Carolina at Chapel Hill,
and in the Integrated Toxicology Program at Duke University.

Dr. Birnbaum's research and many of her publications focus on the pharmacokinetic behavior of
environmental chemicals; mechanisms of actions of toxicants, including endocrine disruption; and linking
of real-world exposures to health effects. Dr. Birnbaum has received numerous awards and recognitions,
including election to the Institute of Medicine of the National Academies in October 2010, one of the
highest honors in the fields of medicine and health.

A native of New Jersey, Dr. Birnbaum received her M.S. and Ph.D. in Microbiology from the University of
Illinois at Urbana-Champaign.

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James H. Johnson, Jr. | U.S. EPA

Session 1 - Welcome and Introduction (moderator)

Dr. James H. Johnson, Jr., is the Director of the National Center for Environmental Research in EPA's ORD.
In this role, Dr. Johnson continues a life-long career dedicated to sustaining and advancing scientific
research and education initiatives supporting environmental protection, q u a I ity-of-l if e programs, and
environmental workforce development.

Dr. Johnson has served on numerous committees and boards for the National Academies, EPA, and
academic institutions. He is a member of the Anne Arundel Community College (Maryland) Board of
Trustees, and is Professor Emeritus of Civil Engineering and Dean Emeritus of the College of Engineering,
Architecture, and Computer Sciences at Howard University. Dr. Johnson is a member of the American
Water Works Association and the Association of Environmental Engineering and Science Professors. He is
also a fellow of the American Society of Civil Engineers and Board Certified Environmental Engineer of the
American Academy of Environmental Engineers and Scientists.

Dr. Johnson earned his Ph.D. in Applied Sciences from the University of Delaware and received a M.S. from
the University of Illinois and a B.S. in Civil Engineering from Howard University.

Ruth Etzel | U.S. EPA

Session 1 - Welcome and Introduction

Session 11 - Next Steps for Collaboration Between the Children's Environmental Health Centers and
the Pediatric Environmental Health Specialty Units

Dr. Ruth Etzel is the Director of EPA's Office of Children's Health Protection. During 20 years as a
Commissioned Officer in the U.S. Public Health Service, she served in a variety of public-sector leadership
positions including: U.S. Centers for Disease Control and Prevention (Founding Chief of the Air Pollution
and Respiratory Health Branch), U.S. Department of Agriculture (Director of the Division of Epidemiology
and Risk Assessment), and U.S. Indian Health Service (Research Director at the Alaska Native Medical
Center).

Dr. Etzel is the founding editor of Pediatric Environmental Health (a 3rd edition was published by the
American Academy of Pediatrics in 2012). This influential book has helped train thousands of doctors who
care for children about how to recognize, diagnose, treat, and prevent illness in children from hazards in
the environment. She has worked extensively with international organizations to educate health
professionals about environmental health and to build their capacity to conduct environmental
investigations. From 2009 to 2012, Dr. Etzel served as the Senior Officer for Environmental Health
Research in the Department of Public Health and Environment at the World Health Organization in
Geneva, Switzerland.

Dr. Etzel has a broad background in public health, with specific training and expertise in pediatrics,
preventive medicine, and children's environmental health. After completing a residency in pediatrics, she
became a Robert Wood Johnson Clinical Scholar at the University of North Carolina at Chapel Hill.

Patrick Breysse | ATSDR, CDC

Session 1 - Welcome and Introduction

Dr. Pat Breysse joined CDC in December 2014 as the Director of the National Center for Environmental
Health and ATSDR. In this role, Dr. Breysse leads CDC's efforts to investigate the relationship between

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environmental factors and health. He is also a board certified Industrial Hygienist and an editorial review
board member for the Journal of Exposure Science and Environmental Epidemiology.

Dr. Breysse came to CDC from The Johns Hopkins University where he served as Associate Chair for
Educational Programs within the Department of Environmental Health Sciences, Program Director for the
Industrial Hygiene Training Program, and Co-Director of the Johns Hopkins Center for Childhood Asthma
in the Urban Environment. During his 30 years at Johns Hopkins, Dr. Breysse established a long-standing
expertise in environmental health and a strong record as a leader in the field. He has published over 200
peer-reviewed journal articles and has presented at more than 25 scientific meetings in just the past 5
years. Dr. Breysse's research has focused on the evaluation and control of chemical, biological, and
physical factors that can affect health, with a particular concentration on risk and exposure assessment.

Dr. Breysse received his Ph.D. in Environmental Health Engineering from The Johns Hopkins University in
1985 and completed postdoctoral training at the British Institute for Occupational Medicine in Edinburgh,
Scotland.

Gail Christopher | W.K. Kellogg Foundation

Session 2 - Keynote Speaker

Dr. Gail Christopher is Vice President for Policy and Senior Advisor at the W.K. Kellogg Foundation. In this
role, she serves on the President's cabinet that provides overall direction and leadership for the
foundation. Since joining the foundation in 2007, she has served as Vice President for Program Strategy
with responsibility for multiple areas of programming, including Racial Equity; Food, Health & Weil-Being;
Community Engagement and Leadership. She is also responsible for place-based programming in New
Orleans and New Mexico.

Bruce Lanphear | Simon Fraser University

Session 8 - Keynote Speaker

Dr. Bruce Lanphear is a Clinician Scientist at the Child & Family Research Institute at the British Columbia
Children's Hospital and a Professor in the Faculty of Health Sciences at Simon Fraser University in
Vancouver, British Columbia. His primary goal is to help quantify and ultimately prevent disease and
disability (asthma, learning problems and ADHD) due to exposures to environmental contaminants and
pollutants. Over the past decade, Dr. Lanphear has become increasingly displeased by our inability to
control the "pandemic of consumption"—the highly preventable, worldwide epidemic of chronic disease
and disability due to industrial pollutants, environmental contaminants, and excess consumption. He is
leading an effort to build the online Atlas of Environmental Health to enhance public understanding of
how environmental factors influence human health.

Michael Lu | Health Resources and Services Administration

Session 5 - Lifestage Approach to Prematurity

Dr. Michael Lu was named associate administrator of maternal and child health of the Health Resources
and Services Administration (HRSA) in 2011. HRSA is an agency of the U.S. Department of Health and
Human Services. He is also Director of the Maternal and Child Health Bureau (MCHB), which aims to
provide leadership, in partnership with key stakeholders, to improve the physical and mental health,
safety and well-being of the maternal and child health population. Through its Title V program, MCHB

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serves 40 million women, infants, children, adolescents, and their families each year, including fathers
and children with special health care needs.

Dr. Lu joined HRSAfrom the University of California, Los Angeles Schools of Medicine and Public Health,
where he was associate professor of obstetrics, gynecology and public health. Dr. Lu brings years of
experience in MCH research, practice, and policy to his post at HRSA. Prior to his appointment to head up
MCHB, Dr. Lu chaired the Secretary's Advisory Committee on Infant Mortality. He has served on two
Institute of Medicine (IOM) Committees (Committee on Understanding Premature Birth and Assuring
Healthy Outcomes, and Committee to Reexamine IOM Pregnancy Weight Guidelines), and the Centers for
Disease Control and Prevention Select Panel on Preconception Care.

While at UCLA, Dr. Lu was a lead investigator for the National Children's Study. He also led a project to
monitor and improve the quality and safety of maternity care in California. He was best known for his
research on racial-ethnic disparities in birth outcomes, and his visionary leadership on life course. Dr. Lu
taught obstetrics and gynecology at the David Geffen School of Medicine at UCLA, and maternal and child
health at UCLA School of Public Health. He has received numerous awards for his teaching, including
Excellence in Teaching Awards from the Association of Professors of Gynecology and Obstetrics. As an
obstetrician, Dr. Lu has attended over a thousand births, and has been voted one of the Best Doctors in
America since 2005.

Dr. Lu received his B.S. in political science and human biology from Stanford University, his M.S. and
M.P.H. from UC Berkeley, M.D. from UC San Francisco, and residency training in obstetrics & gynecology
from UC Irvine.

Leonardo Trasande | New York University

Session 12 - Keynote Speaker

Dr. Leonardo Trasande is an Associate Professor of Pediatrics and Environmental Medicine at the NYU
School of Medicine, of Health Policy at the NYU Wagner School of Public Service, and in Public Health at
the NYU Steinhardt School of Culture, Education and Human Development. His research focuses on
identifying the role of environmental exposures in childhood obesity and cardiovascular risks, and
documenting the economic costs for policy makers of failing to prevent diseases of environmental origin
in children proactively.

Dr. Trasande is perhaps best known for a 2012 Journal of the American Medical Association study
associating BPA exposure in children and adolescents with obesity, and a 2011 study in Health Affairs
which found that children's exposures to chemicals in the environment cost $76.6 billion in 2008. His
analysis of the economic costs of mercury pollution played a critical role in preventing the Clear Skies Act
(which would have relaxed regulations on emissions from coal-fired power plants) from becoming law.
Dr. Trasande has also published a series of studies documenting increases in hospitalizations associated
with childhood obesity and increases in medical expenditures associated with being obese or overweight
in childhood, studies that have been cited in the Presidential Task Force Report in Childhood Obesity. He
also published another landmark study identifying that a $2-billion annual investment in prevention would
be cost-effective even if it produced small reductions in the number of children who were obese and
overweight. Dr. Trasande has testified before the Senate's Environment and Public Works Committee and
Democratic Policy Committee. His work has been featured on the CNN documentary Planet in Peril and in
National Geographic, and frequently appears on national media, including NBC's Today Show, ABC's
Evening News, and National Public Radio.

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Dr. Trasande received his M.D. from Harvard Medical School, and his M.P.P. from Harvard School of Public
Policy. He completed a residency in pediatrics at Boston Children's Hospital, a Dyson Foundation
Legislative Fellowship in the office of Senator Hillary Rodham Clinton, and a fellowship in Environmental
Pediatrics at the Mount Sinai School of Medicine.

Emanuel Alcala | California State University, Fresno, Central Valley Health Policy
Institute

Session 4 - Social Determinants of Health

Emanuel Alcala joined the Central Valley Health Policy Institute team in May of 2013. As a statistician he
explores data from the Central Valley in an effort to uncover health outcomes. Management of these data
produce reports, graphs, and maps that strive to achieve CVHPI's mission.

After graduating with a B.A. in Psychology at California State University, Fresno, Emanuel earned a M.A.
in Psychology with an emphasis in General/Experimental Psychology. Emanuel has more than four years
of experience in a research setting. His past work includes working with underprivileged children as a
Family Specialist. Emanuel is delighted to contribute to the Valley that has nurtured his education and
hopes to give back to the community.

Kathleen Alexander | Virginia Polytechnic Institute and State University

Session 10 - Emerging Topics in Children's Health

Dr. Kathleen Alexander is Associate Professor in the Department of Fish and Wildlife Conservation at
Virginia Tech. Her research program is directed at exploring and understanding the factors that influence
the emergence and re-emergence of diseases at the human- wildlife-environmental interface. The
program embraces a systems biology approach to ecosystem health integrated with public health,
beginning within host - pathogen dynamics and extending to the livelihoods of communities living with
wildlife, including the impact on ecosystem function and local communities themselves. Dr. Alexander is
also the board president of the Center for African Resource: Animals, Communities, and Land Use
(CARACAL). CARACAL is a not for profit agency dedicated to the conservation of natural resources and
improved rural livelihoods for local communities in Chobe Botswana. Dr. Alexander received her Ph.D.
and D.V.M from the University of California, Davis.

Laura Anderko | Georgetown University

Session 10 - Emerging Topics in Children's Health

Dr. Laura Anderko holds the Robert and Kathleen Scanlon Endowed Chair in Values-Based Health Care at
the Georgetown University School of Nursing & Health Studies and serves as Director of the Mid-Atlantic
Center for Children's Health and the Environment (Region 3's Pediatric Environmental Health Specialty
Unit, Centers for Disease Control and Prevention). She is a scholar and educator in the fields of
epidemiology, public health, and environmental health. Dr. Anderko serves as Co-Chair of the National
Environmental Health Partnership Council and is Vice President of the Healthy Schools Network, a
member of the Regional 3 Health Equity Council (Office of Minority Health), Research Co-Chair for the
Alliance of Nurses for a Healthy Environment, and Chair for the National Center for Children's Vision and
Eye Health Advisory Board (Maternal Child Health Bureau, HRSA). She is a former member of EPA's federal
advisory committees: Children's Health Protection Advisory Committee, National Drinking Water Advisory
Committee, and National Environmental Justice Advisory Committee's Research Workgroup. In July 2013,
Dr. Anderko was honored by the White House for her work in climate change and public health.

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Dr. Anderko earned her Ph.D. in Public Health and her B.S. in Nursing from the University of Illinois, and
her M.S. in Community Health Nursing at Northern Illinois University.

Carl Baum | Yale University

Session 10 - Emerging Topics in Children's Health (moderator)

Dr. Carl Baum is a Professor of Pediatrics at the Yale University School of Medicine, specializing in Pediatric
Emergency Medicine and Medical Toxicology. Dr. Baum is also the Medical Director of the Pediatric
Environmental Health Specialty Unit Program - Western Operations. He is Director of the Center for
Children's Environmental Toxicology at Yale-New Haven Children's Hospital. In 2005, Dr. Baum received
the Children's Environmental Health Recognition Award from the U.S. EPA Office of Children's Health
Protection.

He received his M.D. from the University of Pennsylvania, a M.Sc. in Geological Sciences from Brown
University, and a B.A. in Earth Sciences from Dartmouth College. He completed his residency in pediatrics
at Children's Hospital of Philadelphia and fellowships in Pediatric Emergency Medicine and Medical
Toxicology at Boston Children's Hospital.

Susan Buchanan | University of Illinois, Chicago

Session 7c - Reproductive Health

Dr. Susan Buchanan is a Clinical Associate Professor of Environmental and Occupational Health Sciences
at the University of Illinois at Chicago School of Public Health. She is also the Associate Director of the
Occupational Medical Residency Program at the University of Illinois Hospital. Dr. Buchanan is dual
certified in Family Medicine and Preventive Medicine. She practiced primary care for more than a decade
before joining the department, adding teaching and research to her active practice. Her practice involves
the evaluation of pediatric and adult patients with health problems related to their environment in the
workplace and community.

Dr. Buchanan also directs the Great Lakes Center Pediatric Environmental Specialty Unit for Region 5. Her
research interests include the health of children and minority, low-income, and immigrant workers and
reproductive environmental health, areas in which she has published a series of peer-reviewed studies.

Dr. Buchanan received her M.D. from Ohio State University and her M.P.H from the University of Illinois
at Chicago.

Sally Darney | National Institute of Environmental Health Sciences

Session 9a - Community Outreach and Research Translation, Part I

Dr. Sally Darney is Editor in Chief of the NIEHS Journal Environmental Health Perspectives (EHP).
International in scope, EHP covers the wide spectrum of the environmental health sciences, with emphasis
on innovative and interdisciplinary approaches. The journal strives to be a focal point for information
dissemination about the latest research and news in environmental public health, and serves as a forum
for diverse perspectives of science, government, industry, private, and public-interest groups on
important and emerging issues of environmental health.

Dr. Darney previously led an independent research program in reproductive toxicology and epidemiology
in EPA's ORD, publishing over 100 research papers and review articles. In addition to conducting research,
she served as the Director of the Reproductive Toxicology Division in the National Health and

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Environmental Effects Research Laboratory, contributed to EPA reproductive toxicology testing and risk
assessment guidelines, and represented EPA on the Interagency Coordinating Committee for the National
Children's Study and the Children's Health Federal Taskforce workgroup on Reducing Racial and Ethnic
Asthma Disparities. Most recently, Dr. Darney helped develop the research frameworks and strategic
directions for ORD's National Research Programs in Sustainable and Healthy Communities and Chemical
Safety for Sustainability. In the broader scientific community, she is Past President of the Society for the
Study of Reproduction and the American Society for Andrology, and has served as an Associate Editor for
Biology of Reproduction, and the Journal of Toxicology and Environmental Health, and as Co-Editor-in-
Chief of the Journal of Andrology.

Dr. Darney received her Ph.D. in Anatomy and Reproductive Biology from the University of Hawaii and
completed a postdoctoral fellowship at The Johns Hopkins University Bloomberg School of Public Health.

Greg Diette | Johns Hopkins University

Session 4 - Social Determinants of Health

Dr. Gregory Diette is Professor of Medicine, Epidemiology and Environmental Health Sciences. He is a
pulmonologist with a practice devoted to the care of patients with obstructive lung diseases, including
asthma and chronic obstructive pulmonary disease (COPD). He has an extensive portfolio of patient-based
research in asthma and COPD, supported by the National Institutes of Health and other sponsors. Dr.
Diette's current research focuses on identifying factors that cause or provoke asthma with special interest
in air pollutants (PM, N02, secondhand smoke) and allergens (including mouse) that are especially
problematic in inner-city homes. His research includes the effects of these pollutants and allergens on
inflammation and oxidative stress. More recently, his research has been examining how dietary patterns,
especially a Western-style diet, may increase susceptibility to inhalable pollutants and allergens.

Dana Dolinoy | University of Michigan

.»ess i on a C3 si ^ in cyclic? a tC3^

Dr. Dana Dolinoy serves as Associate Professor in the Departments of Environmental Health Sciences and
Nutritional Sciences at the University of Michigan School of Public Health and leads the Environmental
Epigenetics and Nutrition Laboratory. This laboratory investigates how nutritional and environmental
factors interact with epigenetic gene regulation to shape health and disease. She also contributes as an
investigator in the NIEHS/EPA University of Michigan Children's Environmental Health and Disease
Prevention Research Center, investigating early exposure to bisphenol A, lead and phthalates, epigenetics,
and later-in-life body weight and hormone outcomes. Dr. Dolinoy also leads the Biological Response
Indicators Resource of M-CHEAR, a laboratory hub within the NIEHS-funded Children's Health Exposure
Analysis Resource network (Principal Investigator: John Meeker). In 2011, she received the Norman
Kretchmer Memorial Award from the American Society for Nutrition and the Classic Paper of the Year
Award from Environmental Health Perspectives.

Dr. Dolinoy holds a Ph.D. in Genetics and Genomics and Integrated Toxicology from Duke University, an
M.Sc. in Environmental Sciences and Engineering from the Harvard School of Public Health, and a B.A. in
Environmental Sciences and Policy and Spanish from Duke University.

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Elaine Faustman | University of Washington

Session 7b - Exposome

Dr. Elaine Faustman is a Professor of Environmental and Occupational Health Sciences at the University
of Washington School of Public Health. She is an elected fellow of the Society of Toxicology and the
American Association for the Advancement of Science and has served on the National Toxicology Program
Board of Scientific Counselors, the National Academy of Sciences Committee on Toxicology, and numerous
editorial boards. She currently chairs the National Academy of Sciences Committee on Developmental
Toxicology.

Dr. Faustman is Director of the NIEHS/EPA Center for Child Environmental Health Risks Research, which
aims to understand the biochemical, molecular, and exposure mechanisms that define children's
susceptibility to pesticides. In addition, researchers are working to assess pesticide risks to normal
development and learning. Her research interests include understanding mechanisms of developmental
and reproductive toxicants, characterizing in vitro techniques for developmental toxicology assessment,
development of biologically based dose-response models for noncancer risk assessment, and
development of decision-analytic tools for incorporating new scientific findings into risk assessment and
risk management decisions.

Dr. Faustman received her Ph.D. in Toxicology from Michigan State University in 1980.

Mai da Galvez | Icahn School of Medicine at Mount Sinai

Session 7a - Obesity

Dr. Maida Galvez is an Associate Professor in the Departments of Preventive Medicine and Pediatrics at
the Mount Sinai Icahn School of Medicine. A board certified Pediatrician, she completed the Academic
Pediatric Association-sponsored fellowship in Environmental Pediatrics at Mount Sinai in New York. She
directs the Region 2 Pediatric Environmental Health Specialty Unit serving New Jersey, New York, Puerto
Rico, and the U.S. Virgin Islands. She served as Co-Principal Investigator and as a New Investigator of the
community-based participatory research project "Growing Up Healthy in East Harlem," examining the
environmental determinants of childhood obesity. She is also Co-Investigator of an NIEHS/NCI-funded
project assessing environmental determinants of puberty in girls, part of the multicenter Breast Cancer
and the Environment Research Project. Her areas of interest include community-engaged research, urban
built environment, endocrine disruptors, and childhood growth and development. Dr. Galvez currently
serves on EPA's Scientific Advisory Board and CDC's National Environmental Health Partnership Council.

She received her M.D. and M.P.H. from Mount Sinai School of Medicine, trained in the Social Pediatrics
Residency Program at Children's Hospital at Montefiore, Albert Einstein College of Medicine, and
completed her Pediatric Chief Residency at Jacobi Medical Center, Bronx, New York.

Andrew Geller | U.S. EPA

Session 4 - Social Determinants of Hea	derator)

Dr. Andrew Geller is the Deputy National Program Director for the Sustainable and Healthy Communities
Research Program at EPA. Dr. Geller has worked with scientists across the Agency to develop EPA's
research and public education initiative on Aging and Environmental Health. He became engaged with the
Agency's Environmental Justice efforts as a result of involvement with U.S. EPA's Region 5 and as co-lead
of the EPA's 2009 workshop on Advancing the Science and Practice of Cumulative Risk Assessment.

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Dr. Geller earned his M.S. and Ph.D. in Cognitive and Experimental Psychology at the University of
Michigan and received his B.A. in Biological Basis of Behavior/Psychology from the University of
Pennsylvania. Dr. Geller completed postdoctoral training in Neurotoxicology at the University of North
Carolina at Chapel Hill's Center for Environmental Medicine and Lung Biology and with NHEERL through a
National Research Service Award from NIEHS.

Previously, Dr. Geller was Chief of the Exposure Modeling Research Branch. He also served as the Assistant
Laboratory Director for the core research program in Human Health and Computational Toxicology at the
EPA National Health and Environmental Effects Research Lab (NHEERL).

Gary Ginsberg | Connecticut Department of Public Health

Session 10 - Emerging Topics in Children's Health

Dr. Gary Ginsberg is a toxicologist for the Connecticut Department of Public Health and a lecturer at the
Yale School of Public Health. He serves on a number of national committees including EPA's Science
Advisory Board, the National Academy of Sciences, and EPA's Children's Health Protection Advisory
Committee. His research focuses on the unique susceptibilities of children to environmental toxicants. He
evaluates risks and sets standards for contaminants in soil, drinking water, food, air and consumer
products. Dr. Ginsberg has been called on by other federal agencies to provide reviews including OSHA
(silica workplace standard), CPSC (cadmium in children's jewelry) and FDA (dental amalgam). His risk
assessments on fish contaminants, syntheticturf fields, acrylamide, cadmium, and assessments pertaining
to risks in children and those with genetic polymorphisms have been published in peer review journals.
Dr. Ginsberg won the Society of Toxicology best risk assessment paper of the year award in 2009, and in
2006 he co-authored a book for the lay public called "What's Toxic What's Not". He received his doctorate
degree from the University of Connecticut.

Kimberly Gray | National Institute of Environmental Health Sciences

Session 11 - Next Steps for Collaboration Between the Children's Environmental Health Centers and
the Pediatric Environmental Health Specialty Units (moderator)

Dr. Kim Gray is the Health Scientist Administrator for the Population Health Branch at NIEHS. She directs
the Children's Environmental Health and Disease Prevention Research Centers Program for NIEHS. She is
a member of the World Health Organization's Collaborating Centres Network for Children's Environmental
Health at NIEHS. The Network supports translation of children's environmental health research findings
into effective public health strategies to improve children's health around the world. She is the NIEHS
Senior Advisor for Certificates of Confidentiality and a member of the NIEHS Protocol Advisory Board and
the NIEHS Institutional Review Board.

Dr. Gray returned to NIEHS in 2001 after completing a postdoctoral fellowship in the NIEHS Epidemiology
Branch, for which she examined the long-term effects of polychlorinated biphenyl exposure during
pregnancy and childhood development using specimens and data collected from the Collaborative
Perinatal Project.

Dr. Gray received her B.S. degree in Behavioral Neuroscience and her Ph.D. in Epidemiology from the
University of Pittsburgh. During her graduate training, Dr. Gray gained experience as an interviewer and
assessor while working on the Women's Health Initiative and Cardiovascular Health study. She received a
National Research Service Award from the National Institute on Alcohol Abuse and Alcoholism for her
work with Dr. Nancy Day examining the long-term effects of prenatal exposure to alcohol, marijuana, and

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tobacco and her work with childhood outcomes on the Maternal Health Practices and Child Development
pregnancy cohort.

Michael Hatcher | ATSDR, CDC

Session 5 - Lifestage Approach to Prematurity (moderator)

Dr. Hatcher is a public health professional with 38 years of health promotion and disease prevention
experience at the local, state, and federal levels of public health. He has led health promotion and disease
prevention planning, initiative development and implementation that resulted in measurable population-
level health improvements. His experience includes health system operation and performance
improvement as well as health services research at the interface of population health and personal health
care. His career has offered him many opportunities to participate in and undertake leadership roles in
new state and national public health initiatives, including:

•	Managing development and implementation of the 1990 Texas Health Promotion Disease
Prevention Objectives,

•	Consulting with states establishing year 2000 Healthy People Objectives,

•	Responding to the public health capacity development needs identified in the 1988 Future of
Public Health report published by the Institute of Medicine,

•	Developing training and other tool to introduce managed care to public health departments,

•	Developing and testing National Public Health Performance Standards,

•	Articulating principles of community engagement and leading writing of the 1997 edition of
Principles of Community Engagement and guiding design and participating in writing the 2011
Principles of Community Engagement: Second Edition, and

•	In 2003 he took the lead on ATSDR's primary care provider and health systems engagement to
improve environmental exposure recognition, exposure prevention, and treatment of illnesses
resulting from exposures to hazardous substances in the environment.

Dr. Hatcher is a native of Tennessee. He received his undergraduate public health degree and his Masters
of Public Health from the University of Tennessee. His doctorate of public health was earned from the
University of North Carolina at Chapel Hill, where he was a Fellow in the Leadership Doctorial Program
within the Department of Health Policy and Administration.

Irva Hertz-Picciotto | University of California, Davis

Session 6 - Neurodevelopmental Disorders

Dr. Irva Hertz-Picciotto, Professor at the University of California Davis MIND Institute and Director of the
NIH-funded UC Davis Environmental Health Sciences Center, is an environmental epidemiologist with over
300 scientific publications addressing environmental exposures, including metals, pesticides, air
contaminants and endocrine disrupting compounds; their interactions with nutrition, genes or social
factors; and their effects on pregnancy, the newborn, and child development. She designed and directs
CHARGE (Childhood Autism Riskfrom Genes and Environment), the first large, comprehensive population-
based study of environmental factors in autism, and MARBLES (Markers of Autism Risk in Babies -
Learning Early Signs) to search for early markers that will predict autism, starting in pregnancy. Hertz-
Picciotto has also led several cohort studies of toxic chemicals and both pregnancy outcomes and early
child development in Mexico, Chile, and Eastern Europe.

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She has served on scientific advisory panels for the U.S. Environmental Protection Agency, the NIH
National Toxicology Program, and the California Governor's Proposition 65 committee. She was elected
President of two major professional epidemiology societies, and chaired four National Academy of
Sciences/Institute of Medicine Panels on: Agent Orange and Vietnam Veterans, and Breast Cancer and the
Environment. Dr. Hertz-Picciotto has taught epidemiologic methods on four continents and mentored
over 75 graduate students and postdoctoral scholars. In 2011, she received the Goldsmith Lifetime
Achievement Award from the International Society for Environmental Epidemiology. Recently she co-
founded (with the Learning Disabilities Association) Project TENDR (Targeting Environment and Neuro-
Developmental Risks), a collaborative effort of scientists, clinicians, policy-makers and advocates that aims
to decrease the incidence of neurodevelopmental disorders by reducing neurotoxicant exposures that
contribute to them.

Dr. Hertz-Picciotto received her B.A., M.P.H., M.A., and Ph.D. from the University of California, Berkeley.

Katie Huffling | Alliances of Nurses for Healthy Environments

Session 10 - Emerging Topics in Children's Health

Katie Huffling is a Certified Nurse-Midwife and is the Director of Programs for the Alliance of Nurses for
Healthy Environments where she directs projects related to environmental health nursing practice,
research, education, and policy and advocacy. She is part of a national and international network of nurses
that work to integrate environmental health into nursing education and provide guidance and resources
to pregnant women, parents, and others about health risks to children and their families.

Ms. Huffling has also written numerous peer-reviewed articles on environmental health problems and
their relationship to pregnancy. In addition, she has developed an assessment tool for nurses and other
clinicians to assess for environmental exposures of pregnant women. In 2011, she was a fellow for Reach
the Decision Makers program at the University of California, San Francisco's Program on Reproductive
Health and the Environment.

Dean Jones | Emory University

Session 7b - Exposome

Dr. Dean Jones is a professor in the Department of Medicine (Pulmonary Division) with secondary
appointments in Biochemistry and Pediatrics at Emory University, Atlanta, Georgia. He joined Emory
University as an Assistant Professor of Biochemistry in 1979 and was subsequently promoted to Associate
Professor in 1985 and to Professor of Biochemistry in 1990. He became Professor of Medicine and Director
of the Clinical Biomarkers Laboratory in 2003. Dr. Jones also serves as the Integrated Health Sciences
Facility Core Director of the NIEHS-supported HERCULES Exposome Research Center.

Dr. Jones' research career has included studies of mitochondrial mechanisms of toxicity, redox systems
biology, oxidative stress and antioxidant systems, compartmentation of metabolism, and high-resolution
metabolomics. He currently is focused on applications of ultrahigh-resolution mass spectrometry for
precision medicine, with a long-term goal to use this as a foundation to sequence the exposome. These
methods enable measurement of thousands of low abundance metabolites, including those derived from
innate metabolism, the environment, diet, drugs, and the microbiome. Dr. Jones has recently focused on
low-level environmental exposures, such as dietary cadmium, which can influence onset and progression
of chronic diseases, and has active NIH-supported research programs on the metabolomics of
cardiovascular, lung, eye, neurodegenerative, and infectious diseases and aging. He collaborates
extensively on studies of diverse populations and disease processes.

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Dr. Jones received his Ph.D. in Medical Biochemistry from Oregon Health Sciences University, Portland, in
1976. He studied Nutritional Biochemistry at Cornell University and MolecularToxicology atthe Karolinska
Institute as a postdoctoral fellow.

Margaret Karagas | Dartmouth College
Session 8 - Keynote Speaker (moderator)

Dr. Margaret Karagas is Professor and Department Chair of Epidemiology at the Dartmouth College Geisel
School of Medicine and Director of the Dartmouth Children's Environmental Health and Disease
Prevention Research Center.

Dr. Karagas' research encompasses several epidemiological studies focusing on the etiology of human
cancers and on adverse pregnancy and children's health outcomes. Her studies focus on identifying key
factors—prevalent environmental exposures, host factors, and mechanisms—that affect health from
infancy to adult life, and application of novel methods and technologies to understand disease
pathogenesis. These include interdisciplinary studies of temporal changes in the incidence rates of
keratinocyte cancers and emergent exposures, such as indoor tanning, and drinking water contaminants.
Dr. Karagas has established a cohort of pregnant women and their offspring in New Hampshire to assess
the sources and potential health impacts of arsenic and other exposures—on childhood infection,
allergy/atopy, growth and neurodevelopment—through the Children's Center. Her work involves
collaborative studies of exposure biomarkers, individual susceptibility, and biological response to
environmental agents, including the developing microbiome and immune response.

Dr. Karagas received her Ph.D. from the University of Washington.

Catherine Karr | University of Washington

Session 9 >	immunity Outreach and Research Translation, Part I ant	derator)

Dr. Catherine Karr is a pediatric environmental medicine specialist and environmental epidemiologist. She
has a primary appointment in the Department of Pediatrics, Joint in Environmental & Occupational Health
Sciences, and Adjunct in Epidemiology. She is affiliated with the University of Washington Center for
Children's Environmental Health Research and the Pacific Northwest Center for Agricultural Safety and
Health. Dr. Karr has a general pediatric practice at the University of Washington Pediatric Clinic at
Roosevelt and provides specialty pediatric environmental medicine consultation at this site and at the
Harborview Medical Center.

As Director of the Northwest Pediatric Environmental Health Specialty Unit, she sets the direction for
outreach and education and for responding to queries from health care providers, government officials,
and families regarding health risks associated with environmental exposures. She is involved in policy and
education through the American Academy of Pediatrics National Council on Environmental Health. Her
research areas include environmental contaminants and pediatric respiratory health, including asthma,
health of farmworker children, and global children's environmental health.

Dr. Karr received her Ph.D. in Epidemiology, M.D., and M.S. in Toxicology at the University of Washington,
and her B.S. in Biology at the University of Michigan.

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Susan Korrick | Harvard University

Session 6 - Neurodevelopmental Disorders

Dr. Susan Korrick is an Assistant Professor of Medicine at Harvard Medical School and an Assistant
Professor in Environmental Health at the Harvard T.H. Chan School of Public Health, with an appointment
as an Associate Physician at Brigham and Women's Hospital. She is an Investigator with the EPA/NIEHS
Children's Centers at Dartmouth College and the University of Illinois.

Dr. Korrick's research focuses on the developmental and neurocognitive toxicities of environmental
contaminants, including metals, organochlorine pesticides, and polychlorinated biphenyls, and short half-
life compounds such phenols and phthalates. The core of her research is the development (as Principal
Investigator) of the New Bedford Cohort, an ongoing birth cohort study, results of which have expanded
understanding of the neurobehavioral impacts of a variety of early life metal (e.g., methylmercury) and
organochlorine exposures. More recently, Dr. Korrick has extended her research to include collaborative
studies of outcomes-based risk assessment and methods development for analyzing exposure mixtures in
the New Bedford Cohort. She has segued her experience with birth cohort studies into close collaborative
efforts with other longitudinal studies, most notably two pregnancy cohorts developed via NIEHS/EPA
Children's Centers at the University of Illinois and Dartmouth Medical School.

De-Kun Li | Kaiser Permanente

Session 10 - Emerging Topics in Children's Health

Dr. De-Kun Li is a Senior Research Scientist at the Division of Research, Kaiser Permanente Northern
California. He is a reproductive and perinatal epidemiologist with extensive experience conducting
epidemiologic studies examining in-utero exposures in relation to pregnancy outcomes and early
childhood diseases, including childhood obesity and asthma, preterm delivery, low birthweight, birth
defects, miscarriage and SIDS. He has more than 88 peer-reviewed publications, of which he first-authored
41 and was the senior author for another 18. He is an existing member of an advisory committee for the
Dartmouth Children's Environmental Health and Disease Prevention Research Center, and currently
serves as the Associate Editor of the American Journal of Epidemiology.

Dr. Li's current research focuses on developmental origins of pregnancy outcomes and childhood diseases
which include examination of (1) in-utero environmental exposures including endocrine disruptors (e.g.,
BPA) and electromagnetic fields (EMF), (2) safety and effectiveness of medication use during pregnancy,
and (3) gene-environment interactions. Throughout his professional life, he has made important
contributions to the understanding of (a) factors associated with reduction in SIDS risk, (b) health effects
due to exposure to EMF, (c) adverse effects of in-utero exposure to caffeine, (d) impact of exposure to
environmental endocrine disruptors, (e) risk and benefit of treating maternal depression during
pregnancy, (f) parental genetic contribution to the risk of preterm delivery, and (g) benefits of treating
herpes infection during pregnancy.

Dr. Li completed his medical training and master's degree in Public Health at Shanghai Medical University,
Shanghai, China. He then received his Ph.D. in epidemiology and post-doctoral degree in environmental
and molecular epidemiology from the University of Washington, Seattle.

Jennifer Lowry | Children's Mercy Hospital

Session 9a - Community Outreach and Research Translation, Part I

Dr. Jennifer Lowry is the Director for the Mid-America Pediatric Environmental Health Specialty Unit for
EPA Region 7 and a Medical Toxicology liaison to the Region 7 ATSDR. She is the Chair of the American

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Academy of Pediatrics' Council on Environmental Health and a current member of the Children's Health
Protection Advisory Committee for EPA. Dr. Lowry is board certified in Pediatrics and Medical Toxicology
and spent 5 years as the Medical Director to the Kansas Poison Control Center. She is the Chief for the
Section of Clinical Toxicology at Children's Mercy Hospital and Professor in Pediatrics at the University of
Missouri.

Dr. Lowry received her M.D. at the University of South Dakota School of Medicine. She completed a
Pediatric Residency and Clinical Pharmacology/Medical Toxicology Fellowship at the Children's Mercy
Hospital in Kansas City, Missouri.

Rob S. McConnell | University of Southern California

Session 7a - Obesity

Dr. Rob McConnell is Professor of Preventive Medicine and Director of Southern California Children's
Environmental Health Center at the University of Southern California, where he has studied the effects of
air pollution on children's health. The role of air pollution in obesity and its metabolic consequences is a
major current focus of interest and the theme of the Children's Center. He has examined associations of
air pollution with asthma and lung function, autism, and early markers for cardiovascular disease. Other
interests include developing methods for estimating the burden of disease associated with near-roadway
air pollution and for assessing exposure in environmental epidemiology. He directs the Career
Development Program of the NIEHS-supported Southern California Environmental Health Sciences Center
and a fellow of the American Association for the Advancement of Science.

John Meeker | University of Michigan

Session 7c - Reproductive Health

Dr. John Meeker is a Professor of Environmental Health Sciences and Associate Dean for Research at the
University of Michigan School of Public Health. He is also a Certified Industrial Hygienist. Dr. Meeker is the
Principal Investigator on numerous large-scale research studies, Associate Editor of Environmental Health
Perspectives, and has served on various peer-review and advisory panels for EPA, NIH, and others in recent
years. His work is wide-ranging and focuses on defining sources, magnitudes, and consequences of human
exposure to environmental and occupational contaminants, and on identifying and evaluating strategies
to control harmful exposures.

Dr. Meeker's current research involves human exposure science and reproductive and developmental
epidemiology studies of known or suspected endocrine-disrupting chemicals, such as phthalates,
bisphenol A, pesticides, and flame retardants.

Dr. Meeker holds an M.S. and a Sc.D in Environmental Science & Engineering and Exposure, Epidemiology
& Risk, respectively, from Harvard University, where he also completed a postdoctoral fellowship in
Environmental and Reproductive Epidemiology. He received a B.S. in Industrial Technology from Iowa
State University.

Catherine Metayer | University of California, Berkeley

Session 11 - Next Steps for Collaboration Between the Children's Environmental Health Centers and
the Pediatric Environmental Health Specialty Units

Dr. Catherine Metayer is the Principal Investigator of the California Childhood Leukemia Study and
Director of the Center for Integrative Research on Childhood Leukemia and the Environment, a federally

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funded Program Project for a Children's Environmental Health Center in the United States. She is also the
Chair of the Childhood Leukemia International Consortium Studies.

Dr. Metayer is an epidemiologist currently focusing on genetic and environmental risk factors of leukemia
and other cancers in children, adolescents and young adults. Her research portfolio focuses on the
associations between environmental exposures, birth characteristics, medical conditions, nutrition, and
genetic factors and the risk childhood leukemia. She is now expanding her research to other early-onset
solid cancers.

Dr. Metayer received her Ph.D. in Epidemiology from Tulane University School of Public Health and her
M.D. from the University of Bordeaux II in France. Prior to joining UC Berkeley, she was a Visiting Scientist
at the U.S. National Cancer Institute investigating the risk of second primary cancers.

Mark Miller | University of California, San Francisco

Session 9b - Community Outreach and Research Translat t II

Dr. Mark Miller is an Assistant Clinical Professor of Pediatrics and Internal Medicine in the Division of
Occupational and Environmental Health at the University of California, San Francisco (UCSF). He is also
the Co-Director of the Western States Pediatric Environmental Health Specialty Unit at UCSF and the
Director of the Children's Environmental Health Program at the California Environmental Protection
Agency. Dr. Miller leads the COTC Core at the University of California, Berkeley's Center for Integrative
Research on Childhood Leukemia and the Environment, where a diverse team of scientists is investigating
possible environmental causes of childhood leukemia.

Dr. Miller has worked with Physicians for Social Responsibility to develop the Pediatric Environmental
Health Toolkit, a resource to help clinicians incorporate preventive environmental health messages into
routine pediatric care. He spent 13 years as a pediatrician in private practice in a small town in California.
He is a co-author of A Story of Health, a multimedia e-book examining multiple environmental
contributors to health and how they interact with genetics across the lifespan.

Dr. Miller was greatly influenced as a college student when he had the opportunity to visit Minamata,
Japan as a guest of the Minamata Disease Victim's group. Minamata was the site of one of the world's
first mass industrial poisonings, a result of mercury released from a company making material for the
plastics industry. In his own pediatric practice, he began to develop educational materials for patients and
their families to alert them to how environmental exposures could be affecting their health.

Dr. Miller received his M.D. and completed a pediatric residency at Michigan State University. He received
his M.P.H. in Environmental Health Sciences from the University of California, Berkeley and completed a
residency with the California Department of Health Services in Preventive Medicine.

Susan Murphy | Duke University

Session 9b - Community Outreach and Research Translation, Part II

Dr. Susan Murphy is an Associate Professor in the Department of Obstetrics and Gynecology, Division of
Gynecologic Oncology, at Duke University Medical Center, where her laboratory is focused on the
developmental origins of disease and on the epigenetics and novel therapeutic approaches in gynecologic
malignancies. She leads the Duke Epigenetics Research Laboratory and is Director of the NICHES Children's
Environmental Health and Disease Prevention Research Center and Co-Principal Investigator leading the
molecular biology efforts of the Duke-based Newborn Epigenetics Study (NEST). NEST is a longitudinal

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birth cohort study providing new insights regarding the in utero environment's effects on the epigenetic
regulatory regions of imprinted genes.

Her long-term research goals are to identify and utilize epigenetic changes that occur due to early life
exposures, to improve diagnostics, and to develop new intervention and prevention strategies based on
these findings.

Carolyn Murray | Dartmouth College

Session 9a - Community Outreach and Research Translation, Part I

Dr. Carolyn Murray is Director of the Community Outreach and Translation Core for the Dartmouth
Children's Environmental Health and Disease Prevention Research Center. She is a clinician in the Section
of Occupational and Environmental Medicine at Dartmouth-Hitchcock Medical Center and holds faculty
appointments at the Dartmouth Institute for Health Policy and Clinical Practice where she teaches in the
MPH program, and in the Departments of Medicine and Community and Family Medicine at the Geisel
School of Medicine at Dartmouth where she teaches medical students and resident physicians.

Dr. Murray received her M.D. from the University of Virginia, and her M.P.H. and B.S. from the University
of California, Los Angeles. She completed residency training at the University of Colorado and is board
certified in General Preventive Medicine/Public Health and Occupational Medicine.

Kari Nadeau | Stanford University

Session 2 - Keynote Speaker (moderator)

Dr. Kari Nadeau is an Associate Professor of Pediatrics—Immunology and Allergy and Associate Professor
of Otolaryngology at Stanford University School of Medicine. She is also the Director of Basic Science and
Clinical Research at the Sean N. Parker Center for Allergy and Asthma Research at Stanford. Dr. Nadeau
has a broad background in immunology, with specific training and expertise in key research areas on T
cells.

Dr. Nadeau's research focuses on the role of ambient air exposure on the developing immune system in
children, with a focus on understanding the interaction between environment and the immune system by
studying detailed mechanistic studies in T cells. She is working with Drs. Katharine Hammond and Ira Tager
at the University of California, Berkeley, to link mechanistic immunology studies with epidemiological
outcomes of ambient air pollution exposure. Dr. Nadeau has authored and co-authored more than 100
original papers, many of which focus on T cells and health outcomes.

Dr. Nadeau received her Ph.D. in Biochemistry and Immunology from Harvard University, an M.D. degree
from Harvard Medical School, and a B.S. degree from Haverford College.

Frederica Perera | Columbia University

Session 12 - Keynote Speaker (moderator)

Dr. Frederica Perera is a Professor of Environmental Health Sciences. Since 1998, she has served as
Director of the Columbia Center for Children's Environmental Health.

Dr. Perera is internationally recognized for pioneering the field of molecular epidemiology, using
biomarkers to understand links between environmental exposure and disease. Currently, she and her
colleagues are applying advanced molecular and imaging techniques within longitudinal cohort studies of
pregnant women and their children, with the goal of identifying preventable environmental risk factors

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for developmental disorders, asthma, obesity, and cancer in childhood. These include toxic chemicals,
pesticides, and air pollution, with particular focus on adverse effects of prenatal and early childhood
exposures.

Dr. Perera's areas of specialization include prevention of environmentally related developmental
disorders and disease in children, cancer prevention through the use of novel biomarkers, environment-
susceptibility interactions, and risk assessment. Her recent research also addresses the multiple impacts
on children's health and development of fossil fuel combustion—both from the toxic pollutants emitted
and climate change related to C02 emissions. She has written more than 350 publications, including 300
peer-reviewed articles. Dr. Perera has received numerous honors, including, most recently, the Pearl
Award and the Heinz Award for her lifetime achievement in research for the protection of children's
health.

Bradley Peterson | Children's Hospital Los Angeles

Session 8 - Neurodevelopmental Disorders

Dr. Brad Peterson is currently the inaugural director of the Institute for the Developing Mind at Children's
Hospital of Los Angeles. Dr. Peterson also holds a secondary appointment in the Department of Psychiatry
at the Keck School of Medicine of the University of Southern California, where he is director of the Division
of Child and Adolescent Psychiatry. His research includes brain-imaging technologies to gain
understanding of the origins of neurodevelopmental disorders and to map the complex pathways
between the genetic and environmental influences that can trigger their onset or progression.

Dr. Peterson earned his M.D. from the University of Wisconsin School of Medicine in 1987. He completed
his residency in general psychiatry at Massachusetts General Hospital and his postdoctoral research
fellowship at the Yale Child Study Center. Dr. Peterson also completed a clinical fellowship in child
psychiatry at Yale. He has trained adult and child psychoanalysis at Yale and Columbia.

Previously, Dr. Peterson served 13 years as the director of the Center for Developmental Neuropsychiatry
at Columbia University. Before that, he spent 12 years at Yale University, where he served as Director of
Neuroimaging at the Yale Child Study Center. He has published hundreds of papers and received
numerous awards for his accomplishments in childhood neurodevelopmental disorders.

Karen Peterson | University of Michigan

Session 7a - Obesity

Dr. Karen Peterson is a Professor and Chair of the Department of Nutritional Sciences at the School of
Public Health, Research Professor for the Center for Human Growth and Development, and Director of
the Momentum Center: Driving Discovery to End Child Obesity (www.momentumcenter.org), all at the
University of Michigan. She is also an Adjunct Professor of Nutrition at the Harvard School of Public Health.
Dr. Peterson is the Contract Project Investigator for the University of Michigan Children's Environmental
Health and Disease Prevention Center, "Lifecourse Exposures & Diet: Epigenetics, Maturation & Metabolic
Syndrome."

Dr. Peterson's research focuses on understanding the influence of adverse exposures to metals and
endocrine-disrupting chemicals on physical growth, maturation, and markers of metabolic homeostasis
during sensitive developmental periods. She also studies the potential role that dietary quality and
lifestyle behaviors might play in modifying the relationships between environmental exposures and child
health and conducts substantial research on testing interventions to reduce child obesity.

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Stephen Rappaport | University of California, Berkeley

Session 7b - Exposome

Dr. Stephen Rappaport is a Professor of Environmental Health Sciences at the University of California,
Berkeley's School of Public Health. He is a pioneer in the emerging field of Exposure Biology and a
prominent advocate of the concept of the "Exposome" as a new paradigm for Environmental Health.

To discover unknown causes of chronic diseases, Dr. Rappaport's laboratory is conducting exposome-wide
association studies that use untargeted analysis of small molecules and protein adducts in archived blood
samples from diseased and healthy people. He has used environmental measurements and biomarkers to
elucidate the human metabolism of several toxic chemicals, notably benzene, and to quantify
interindividual variability in biomarker levels due to genetic, environmental, and lifestyle factors. Dr.
Rappaport has published extensively in areas related to the assessment of long-term chemical exposures
for purposes of controlling hazards and investigating exposure-response relationships. He has written
more than 230 peer-reviewed publications and has collaborated extensively with investigators
throughout the world.

Dr. Rappaport received his Ph.D and M.S.P.H in Environmental Science and Engineering from the
University of North Carolina and his B.S. in Chemistry from the University of Illinois.

Leslie Rubin | Emory University

Session 4 - Social Determinants of Health

Dr. Leslie Rubin is the President and Founder of Innovative Solutions for Disadvantage and Disability and
a Research Associate Professor in the Department of Pediatrics at Morehouse School of Medicine in
Atlanta, Georgia. He also serves as Co-director of the Southeast Pediatric Environmental Health Unit in
the Department of Pediatrics at Emory University and Medical Director of Developmental Pediatric
Specialists in Atlanta, Georgia.

Dr. Rubin currently provides clinical services, teaches at Morehouse and Emory Schools of Medicine, and
is on several local, regional, national, and international committees and projects that address the needs
of children with developmental disabilities, especially those from low income, minority, and undeserved
communities, with a focus on environmental health disparities.

Dr. Rubin is originally from South Africa where he trained in Pediatrics and came to the United States in
1976. He was at the Hospitals of the Case Western Reserve University in Cleveland, Ohio until 1980 when
he moved to The Children's Hospital in Boston and the Harvard Medical School where he spent 14 years.
In 1994, Dr. Rubin relocated to Atlanta, Georgia to become Director of Developmental Pediatrics at Emory
University. Since 1998, he has been involved with the Southeast Pediatric Environmental Health Specialty
Unit at Emory. In 2004, he joined the faculty at Morehouse School of Medicine and started ISDD, a private,
nonprofit organization, to address the challenges of environmental health disparities in children.

Sheela Sathyanarayana | University of Washington, Seattle Children's Research Institute

Session 11 - Next Steps for Collaboration Between the Children's Environmental Health Centers and
the Pediatric Environmental Health Specialty Units

Dr. Sheela Sathyanarayana is an Associate Professor of Pediatrics and Adjunct Associate Professor in the
Department of Environmental and Occupational Health Sciences at the University of Washington. Dr.
Sathyanarayana serves as the co-director of the Pediatric Environmental Health Specialty Unit in Region
X. Her research interests focus on exposures to endocrine disrupting chemicals including phthalates and

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BPA and their impact on reproductive development. Dr. Sathyanarayana serves as the center director for
The Infant Development and Environment Study, which is a multi-center cohort study of phthalate
exposures in pregnancy and health outcomes in children. She was named Outstanding New Investigator
within the University of Washington Center for Ecogenetics and Environmental Health. She currently
serves as chair for the U.S. Environmental Protection Agency's Children's Health Protection Advisory
Committee and serves on the National Academies of Sciences, National Research Council Committee on
Endocrine-Related Low Dose Toxicity.

Susan Schantz | University of Illinois

Session 6 - Neurodevelopmental Disorders (moderator)

Dr. Susan Schantz is a Professor of Comparative Biosciences at the University of Illinois Beckman Institute
for Advanced Science and Technology. She is also Director of the University of Illinois Children's
Environmental Health Research Center.

Dr. Schantz's research focuses on exposures to endocrine-disrupting chemicals during the prenatal and
adolescent periods, two stages when the nervous system is particularly vulnerable to toxic insult. Her
approach includes laboratory-based animal studies and parallel epidemiological studies. An important
goal of these studies is to determine whether a high fat diet or obesity modify the effects of endocrine-
disrupting chemicals on nervous system development and function.

Dr. Schantz received her Ph.D. from the University of Wisconsin, Madison.

Perry Sheffield | Icahn School of Medicine at Mount Sinai

Session 10 - Emerging Topics in Children's Health

Dr. Perry Sheffield is Assistant Professor of Preventive Medicine and of Pediatrics at the Icahn School of
Medicine at Mount Sinai. Her clinical focus is environmental pediatrics. Much of her research focuses on
the health impacts of air pollution, temperature extremes, and climate change and potential adaptation
strategies. Dr. Sheffield is Deputy Director of the EPA Region 2 Pediatric Environmental Health Specialty
Unit. Dr. Sheffield received her M.D. from the Medical College of Georgia and completed her Pediatrics
Residency at Johns Hopkins Hospital and a fellowship in Pediatric Environmental Health at Mount Sinai.

Patrice Sutton | University of California, San Francisco

Session 9a - Community Outreach and Research Translation, Part I

Patrice Sutton is a Research Scientist spearheading the University of California, San Francisco's Program
on Reproductive Health and the Environment's clinical outreach and translation efforts. She has over 27
years of experience in occupational and environmental health research, industrial hygiene, public health
practice, policy development, and community-based advocacy. As a contractor to California's state health
department from 1987 to 2006, Ms. Sutton was responsible for conducting all aspects of research
investigations spanning a disparate range of issues, including lead poisoning, tuberculosis, asthma, and
pesticide illness.

She has extensive experience collaborating with directly impacted workplace and community-based
populations, labor, and governmental and non-governmental organizations in the development of
research strategies and policy recommendations. Ms. Sutton also has extensive experience as a volunteer
in support of communities and workers impacted by the nuclear weapons production cycle and has
published over 50 peer-reviewed scientific articles and government technical reports.

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Allison Sylvetsky [ George Washington University

Session 10 - Emerging Topics in Children's Health

Dr. Allison Sylvetsky is a Visiting Assistant Professor in the Department of Exercise Science at the George
Washington University Milken Institute School of Public Health. Dr. Sylvetsky joined the Milken Institute
School of Public Health in 2014 from the Intramural Program at the National Institutes of Health (NIH)
where she was a post-doctoral fellow in the Diabetes, Endocrinology, and Obesity Branch of the National
Institute for Diabetes, Digestive, and Kidney Diseases (NIDDK).

Dr. Sylvetsky enjoys teaching and mentoring undergraduate students and is passionate about her primary
research interest studying the metabolic and health effects of artificial sweeteners. Her research interests
also include national trends in beverage consumption, prevention and treatment of childhood obesity,
and psychosocial interventions for treating obesity-related conditions in children and adolescents.
Additionally, Dr. Sylvetsky researches the development of taste preferences and how exposure to specific
foods and beverage ingredients early in life may influence long-term dietary patterns as well as the
development of the intestinal microbiome. In addition to her research and teaching, Dr. Sylvetsky looks
for opportunities to translate nutrition science into clinical and public health practice.

Claudia Thompson | National Institute of Environmental Health Sciences

Session 7b - Exposome (moderator)

Dr. Claudia Thompson is Chief of the Population Health Branch at the National Institute of Environmental
Health Sciences. The Population Health Branch supports diverse programs in population-based,
laboratory-based, and community-engaged research on environmental exposures and their effects on
human health, with an emphasis on how timing of exposure affects health outcomes across the lifespan.
Dr. Thompson has led NIEHS research efforts in response to national disasters, including the coordination
of World Trade Center research and outreach activities; assisted in the NIEHS response to Hurricanes
Katrina and Rita; and most recently, led a trans-NIH Deepwater Horizon Disaster Academic Community
Research Consortium, which she developed to understand the potential health impacts of the Deepwater
Horizon Disaster on community members residing in the Gulf States. Currently, Claudia is co-leading a
trans-NIH working group on household air pollution and cook stoves and has a portfolio of grants related
to cookstove research. She is Program Director for the Environmental Health Sciences Core Centers. Dr.
Thompson received her B.S. in Biology from Bradley University in Peoria, Illinois, and her Ph.D. in
Biochemistry and Nutrition from the University of North Carolina at Chapel Hill.

Nse Witherspoon | Children's Environmental Health Network

Session 10 - Emerging Topics in Children's Health

Ms. Nsedu Witherspoon serves at the Executive Director for the Children's Environmental Health Network
(CEHN), where her responsibilities include successfully organizing, leading, and managing policy,
education/training, and science-related programs. She is a leader in the field of children's environmental
health, and for the past 14 years has served as a key spokesperson for children's vulnerabilities and the
need for their protection, conducting presentations and lectures across the country. Ms. Witherspoon has
held past appointments on the Children's Health Protection Advisory Committee for the Environmental
Protection Agency and the Board for the American Public Health Association. Ms. Witherspoon has a
variety of publications and has the distinct honor of having one of CEHN's leadership awards, the Nsedu
Obot Witherspoon (NOW) Youth Leadership Award, named in her honor. She is also the recent recipient

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of the William R. Reilly Award in Environmental Leadership, from the Center for Environmental Policy at
American University. Ms. Witherspoon has a B.S. in Biology from Siena College and an M.P.H. in Maternal
and Child Health from The George Washington University, School of Public Health and Health Services. A
mother of three children, Ms. Witherspoon is a passionate advocate for all children today and tomorrow.

Tracey Woodruff | University of California, San Francisco

Session 6 - Neurodevelopmental Disorders
Session 7c - Reproductive Health (moderator)

Dr. Tracey Woodruff is a professor in Department of Obstetrics, Gynecology, and Reproductive Sciences
and Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco and the
Director of the Program on Reproductive Health and the Environment. She conducted extensive research
and developed policy on environmental health issues, with a particular emphasis on early-life
development. Her research includes evaluating prenatal exposures to environmental chemicals and
related adverse pregnancy outcomes and characterizing developmental risks. She has authored numerous
scientific publications and book chapters, and has been quoted widely in the press, including USAToday,
the San Francisco Chronicle, and WebMD.

Previously, Dr. Woodruff was a senior scientist and policy advisor in the Office of Policy at was previously
at the U.S. EPA. She was appointed by the governor of California in 2012 to the Science Advisory Board of
the Developmental and Reproductive Toxicant Identification Committee.

Dr. Woodruff received her Ph.D. and M.P.H. in the environmental health sciences from the University of
California, Berkeley. She completed a Pew Postdoctoral Fellowship at the University of California, San
Francisco's, Institute for Health Policy Studies.

Rosalind Wright | Mount Sinai Hospital

Session 4 - Social Determinants of Health

Dr. Rosalind Wright is Professor of Pediatrics, a pulmonary physician, and the Dean for Translational
Biomedical Research at the Icahn School of Medicine at Mount Sinai in New York. She is a developmental
epidemiologist with transdisciplinary training in medicine, environmental health, multi-level modeling and
stress mechanisms. Dr. Wright has an overarching interest in explaining health disparities across the
lifecourse, and her research has primarily focused on early life (prenatal and early childhood) predictors
of developmental diseases including asthma, obesity, neurobehavioral development, and lung growth and
development. A particular focus is on the implementation of studies considering the role of both social
(e.g., individual- and community-level psychosocial stress and other socioeconomic risk factors) and
physical (e.g., air pollution, chemicals, dietary factors, allergens) environmental factors in explaining
health disparities among lower-SES urban populations. Dr. Wright is the PI and Director of the Asthma
Coalition on Community, Environment, and Social Stress (ACCESS) project as well as the Programming of
Intergenerational Stress Mechanisms (PRISM) study funded by the National Institutes of Health at Harvard
Medical School and is a member of the adjunct faculty in the Department of Environmental Health at the
Harvard School of Public Health. This research program explores underlying mechanisms by incorporating
biomarkers of physiological pathways through which psychological stress as well as chemical stressors
may influence health (e.g., altered hypothalamic-pituitary-adrenal axis functioning, altered maturation of
the immune system, disruption of the autonomic nervous system, and epigenetics).

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Marya Zlatnik | University of California, San Francisco

Session 7c - Reproductive Health

Dr. Marya Zlatnik is a Professor of Obstetrics, Gynecology, and Reproductive Sciences at the University of
California, San Francisco, and a Maternal Fetal Medicine specialist, with clinical expertise in the diagnosis
of fetal anomalies. She has a long-standing interest in environmental toxins in pregnancy. Dr. Zlatnik is a
member of UCSF's Program in Reproductive Health & the Environment, Associate Director of UCSF's
fellowship in Maternal Fetal Medicine, and Associate Director for Maternal Fetal Health & the
Environment Program of the UCSF Pediatric Environmental Health Specialty Unit.

Dr. Zlatnik earned her M.D. at the University of Iowa and completed a residency in OB/GYN, a fellowship
in Maternal-Fetal Medicine, and received her Masters of Medical Science at the University of Texas
Medical Branch in Galveston.

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2015 NIEHS/EPA Children's Centers Annual Meeting

October 29-30, 2015

Appendix C - Poster Session Abstracts

Poster
ID

Presenting Author and
Affiliation

Abstract Title k

Number

1

Margaret Adgent
National Institute of
Environmental Health
Sciences

Measuring Estrogen Response in Postnatal
Uterus and Breast Growth: A Study of Soy-
Protein Based Infant Formula

129

2

Emanuel Alcala
Central Valley Health
Policy Institute

Pollution and Preventable Child Illness in
California's Central Valley

129

3

Allison Appleton
University at Albany
School of Public Health

The Albany Infant and Mother Study: Prenatal
Environmental Toxicant and Psychosocial
Stress Exposures, Epigenetic Mechanisms, and
the Gestational Origins of Health Disparities

130

4

John Capitman
Central Valley Health
Policy Institute/California
State University, Fresno

Children's Health and Air Pollution Study—San
Joaquin Valley: Transit Exposures During
Pregnancy

130

5

Gustavo Carlo
University of Missouri

Pilot Data on Air Quality and Exposure to
Environmental Toxicants in Early Childhood
Education Centers

131

6

Kathryn Cottingham
Dartmouth College

Associations of Early Life Water and Dietary
Arsenic Exposure With Subsequent Growth
and Neurodevelopment

131

7

Kathryn Cottingham
Dartmouth College

Elemental Signatures in Infant Urine Reflect
Dietary Patterns

132

8

Brett Doherty
University of North
Carolina at Chapel Hill

Prenatal Exposure to Phthalates and
Performance on the Bayley Scales of Infant
Development-ll in a Population of Young
Urban Children

132

9

Elaine Faustman
University of Washington

Center for Child Environmental Health Risks
Research: Epigenetics and Exposome
Assessment for Neurodevelopment

133

10

Lisa Gilmore

The Cadmus Group, Inc.

Spreading the Word: Home Visits Reduce
Indoor Triggers and Improve Asthma Control

133

11

S. Katharine Hammond
University of California,
Berkeley

Children's Health and Air Pollution Study in
the San Joaquin Valley—the UC Berkeley-
Stanford CEHC

134

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E

12

13

14

15

16

17

18

19

20

21

S. Katharine Hammond
University of California,
Berkeley

I

Spatial and Temporal Trends in Traffic-Related
Air Pollution From 1990 to 2015 in Fresno,
California

134

Darryl Hood

The Ohio State University

Application of Citizen Science Risk-
Communication Tools in a Vulnerable Urban
Community

135

Darryl Hood

The Ohio State University

Exposure to Benzo(a)pyrene Confers
Enhanced Susceptibility to Bacterial Infection:
Validation of Research Trajectory One for the
Public Health Exposome Framework

135

Margaret Karagas
Dartmouth College

The Children's Environmental Health and
Disease Prevention Research Center

136

Catherine Karr
University of
Washington/Northwest
PEHSU

Residential Use of a Pyrethroid Pesticide and
Facial Paresthesias in a Toddler

136

Rachel Locke
Children's Environmental
Health Network

Cancer Free Economy Network

137

Sara Lundgren
Dartmouth College

The Effect of Maternal Prenatal Diet on the
Six-Week Infant Stool Microbiome Depends
on Delivery Mode

137

Meredith McCormack
Johns Hopkins University

Healthy Eating Better Breathing: A Dietary
Intervention Study in Asthma

138

Shawn McElmurry
Wayne State University

Two Contemporary Sources of Child Lead
Exposure: Resuspended Soil and Avgas

138

Catherine Metayer
University of California,
Berkeley

Center for Integrative Research on Childhood
Leukemia and the Environment (CIRCLE)

139

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E

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

Mark Miller

Western States PEHSU (at
UCSF), CIRCLE, Cal EPA

I

Increasing Environmental Health Literacy via A
Story of Health Multimedia eBook and CE
Course

139

Hua Fan-Minogue (and
Kari Nadeau)

Stanford University

Mass Cytometry Identifies Unique Monocytes
and T-cell Alterations After Pollution Exposure

140

Meghan Moynihan
University of Michigan

Predictors of Urinary Cadmium Among
Mothers and Children in Mexico City

140

Susan Murphy
Duke University

Neurodevelopment and Improving Children's
Health Following Environmental Tobacco
Smoke Exposure (NiCHES)

141

Amy M. Padula
Stanford University

Traffic-Related Air Pollution, Neighborhood
Socioeconomic Factors and Neural Tube
Defects in the San Joaquin Valley of California

141

Thomas Palys

Geisel School of Medicine

at Dartmouth

Biorepository at Dartmouth: A Resource for
Children's Environmental Health and Disease
Prevention

142

Tracy Punshon
Dartmouth College

Imaging the Placental Metallome in the New
Hampshire Birth Cohort

142

Leslie Rubin
Southeast PEHSU

Break the Cycle of Environmental Health
Disparities in Vulnerable Children

143

Susan Schantz
University of Illinois

New Findings from the Illinois Children's
Center: Spotlight on BPA

143

Brianna Sleezer
Children's Environmental
Health Network

A Blueprint for Protecting Children's
Environmental Health: An Urgent Call to Action

144

Judy Van De Water
University of California,
Davis

UC Davis Center for Children's Environmental
Health and Disease Prevention (CCEH)

144

Marya Zlatnik
University of California,
San Francisco PEHSU, PEEC

Story of Health Multi-Media eBook—
Storytelling to Translate Science for Health
Promotion and Disease Prevention. The Next
Installment: Infertility

145

Zehang Chen

University of Pennsylvania

Low-Level of Environmental Lead Exposure and
Children's Proactive Aggression

145

Jianghong Liu
University of Pennsylvania

Children's Dietary Pattern is Associated With
Blood Lead Levels

146

Jianghong Liu
University of Pennsylvania

Low Blood Lead Concentration is Associated
With Sleep Disturbance in Preadolescents

146

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37

Jianghong Liu
University of Pennsylvania

Low-Level Lead Exposure is Associated with
Delayed Brain Maturation

147

38

Bowen Yao

University of Pennsylvania

Low Level of Lead Exposure is Associated With
Prolonged P300 Latency Among 12 Year Old
Children

147

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1 - Measuring Estrogen Response in Postnatal Uterus and Breast Growth: A Study of Soy-
Protein Based Infant Formula

Margaret Adgent'; David Umbach'; Babette Zemel2; Andrea Kelly2; Joan Schall2; Eileen Ford2;

Kassa Darge2; Walter Rogan'; Virginia Stallings2

'National Institute of Environmental Health Sciences; 2ChiIdren's Hospital of Philadelphia (CHOP)

Soy contains estrogenic isoflavones. Infants exclusively fed soy-protein based formula are exposed to
high concentrations of these estrogenic compounds, but the physiologic response remains
uncharacterized. We examined the postnatal growth of estrogen-responsive tissues in a study of soy-
protein based infant formula. Methods: Our study included 283 infants, all fed either breast milk (BF)
(n=70), cow milk formula (CMF) (n=lll), or soy formula (SF) (n=102) since birth. We estimated uterine
volume (cm3) and breast bud diameter (cm) from repeated ultrasound measurements of the uterus and
breast buds (male and female), obtained at birth and at 4 - 8 week intervals until 28 (boys) or 36 (girls)
weeks. We used natural cubic splines to estimate postnatal organ growth trajectories by feeding group
and tested whether trajectories differed after adjustment for organ size differences at birth (i.e.,
differences that preceded initiation of feeding). Results: Uterine volume decreased rapidly in the first
several postnatal weeks. The rate of involution was significantly slower in SF girls, compared to CMF (p<
0.01) and BF girls (p = 0.01). SF girls' breast buds tended to be larger than those of CMF and BF girls but
grew at a similar rate (p = 0.72 and 0.73, respectively). Boys' breast buds decreased in size with age,
more rapidly among BF boys than among CMF (p=0 .05) or SF (p< 0.01) boys. These feeding-group
differences in boys attenuated after body-weight adjustment. Conclusions: Soy formula feeding was
associated with a slower rate of uterine involution, suggesting an estrogen response.

2 - Pollution and Preventable Child Illness in California's Central Valley

Emanuel Alcala; Lauren Lessard; John A. Capitman
Central Valley Health Policy Institute

Health inequalities among children are prevalent in California's Central Valley and are linked to unique
social and environmental factors that impact adult health and capacity. In this study, we measure
ecological relationships between neighborhood pollution burden, poverty, race and pediatric
preventable disease hospitalization rates. Methods: Preventable disease hospitalization rates were
obtained from the 2012 California Office of Statewide Health Planning and Development database, for 8
Central Valley counties. The pollution burden score was calculated by the California Office of
Environmental Health Hazard Assessment using 11 indicators. We examined the components of the
pollution burden index for any association with potentially preventable respiratory hospitalizations.
Poisson-based negative binomial regression was used for final analysis controlling for poverty, primary
care-shortage areas, and racial/ethnic diversity at the zip code-level. Stratification of sample by
race/ethnicity and age was also incorporated. Results: A 31% reduction in preventable disease
hospitalizations for children under 15 living in low poverty compared to those living in high poverty was
found. With every unit increase in pollution burden, hospitalizations rates increase by 25%, 20%, and
20% in age groups under 1, 1-4 and 5-14, respectively. In most sub-groups of age and race/ethnicity,
hospitalizations increased as neighborhoods became more racially diverse. Conclusion: Understanding
the geographic distribution of disease and impact of individual and community level factors is essential
to expanding access to care and preventive resources to improve the health of children in California's
most underserved population and region.

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3 - The Albany Infant and Mother Study: Prenatal Environmental Toxicant and
Psychosocial Stress Exposures, Epigenetic Mechanisms, and the Gestational Origins of
Health Disparities

Allison Appleton1; Kevin Kiley1; Alex Pieterse'; Carmen J. Marsit2; Lawrence Schell'

1 University at Albany; 2Dartmouth College

Background: Adverse gestational exposures may shape offspring health for a lifetime, likely via
epigenetic mechanisms. The Albany Infant and Mother Study (AIMS) was developed to identify the
molecular mechanisms through which prenatal toxicant and non-chemical/psychosocial stressors
influence child growth and neurodevelopment. AIMS examines these factors among a more
disadvantaged population than has previously been considered. Here, we review AIMS methods and
provide a first look at participant characteristics. Methods: Participants enroll mid-pregnancy at Albany
Medical Center (target n=300). The prenatal assessment includes stress and indoor environment
questionnaires, and biomarkers for trace metals. Outdoor air quality is assessed via geocoding and
spatially resolved models. Epigenetic alterations to growth and neurodevelopment genes will be
analyzed from cord blood. Clinical information and birth size characteristics are abstracted from medical
records. Follow-up at 12 months will assess child neurobehavior and obesity risk. Results: To date, 85
women have enrolled. Participants are from disadvantaged backgrounds: 44% are black or Hispanic, 20%
did not complete high school, and 60% are not married. High levels of prenatal environmental and
psychosocial risks have been observed: 17% smoked during pregnancy, 48% experienced passive smoke
exposure, 22% were depressed, and 52% had >3 major adverse events. Conclusions: AIMS participants
experience a substantial burden of environmental and social risks, which may set infants on health risk
trajectories for a lifetime. Our future work will examine the cumulative impact of these exposures for
epigenetic modulation of child growth and neurodevelopment. Doing so may yield new insights and
opportunities to ameliorate health disparities.

4 - Children's Health and Air Pollution Study—San Joaquin Valley: Transit Exposures During
Pregnancy

John Capitman1,2; Jaymin Kwon2; Kara Zografos2; Katherine Hammond3; Betsey Noth3; Emanuel
Alcala1

1 Central Valley Health Policy Institute 2California State University, Fresno; 3UC Berkeley

To understand the health effects of the polycyclic aromatic hydrocarbons (PAHs) on pregnant women
and children, one component of the Children's Health and Air Pollution Study in the San Joaquin Valley
(CHAPS-SJV), is continuously measuring the spatial and temporal environmental exposure
concentrations to multiple air pollutants. Neighborhood exposure concentrations to multiple air
pollutants are being characterized by real-time monitoring along with time-location data for proximity
to traffic emission. Structured social observation of neighborhood conditions that promote or impede
walking and/or public transportation are also being implemented. The real time concentration of PM2.5,
ultrafine particle number concentrations, black carbon, particle-bound PAHs were continuously and
simultaneously measured from January to February of 2015. Three zip codes in Fresno that also include
EPA approved fixed air monitoring sites were selected. Walking routes (10 routes) were designed to
reflect variability in neighborhood conditions within the three zip codes. The PM2.5, ultrafine particles,
black carbon, and particle-bound PAHs concentrations are compared with stationary PAHs
concentrations and other PM2.5 components as measured by fixed sites. The time-location data were
mapped using GPS loggers. The sharp elevations of air pollutant concentrations were observed when the
mobile air pollutant monitors were closer to roadways with high volume of vehicles. Neighborhood

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mobile air samples were influenced by roadway traffic conditions immediately, such as encountering
with diesel trucks, approaching in close proximity to freeways and/or busy roadways, passing cigarette
smokers, and gardening activity. Average route social disorder correlated with average route PM2.5.

5 - Pilot Data on Air Quality and Exposure to Environmental Toxicants in Early Childhood
Education Centers

Gustavo Carlo; Chung-Ho Lin; Danh Vu; Alexandra Davis; Phuc Vo; Thi Ho; Jane MeElroy; Francisco
Palermo; Susan Nagel

University of Missouri

Background: Children spend as much as ten hours per day, five days per week, in preschool centers.
Preschoolers can be at risk from toxicant exposure from various sources (e.g., cleaning and art supplies,
toys). These compounds can have adverse health effects on the endocrine system. Chemical exposure
has been linked to a number of disorders (e.g., reproductive disorders, autism, depression, diabetes,
ADHD). Children are particularly susceptible to chemical exposures for several reasons: 1) children
breathe more air, eat more food, and drink more water per unit of body weight compared to adults, 2)
children have more direct contact with contaminated surfaces, and 3) children have developing brains,
neuroendocrine and immune systems. Despite these risks, research that examines airborne chemicals in
preschool centers is sparse. Aim: To assess airborne chemicals and toxins in preschool centers with low-
income children. Methods: We selected four Head Start preschool centers with diverse physical
characteristics from a large urban area. Indoor air samples were collected over six months. Outdoor and
residential comparison samples were also collected. Volatile Organic Compounds (VOCs) were sampled
by thermal desorption samplers and concentrations were determined by a thermal desorption gas
chromatography-mass spectrometry (TD-GC-MS) methods. Results: A series of Bonferroni-adjusted t-
tests showed significantly higher levels of several chemicals (e.g., benzenes, chlorinates, endocrine
disruptors, organic solvents) inside classrooms at Head Start centers as compared to residences. Further
analyses revealed significant differences across classroom types (e.g., ground floor, playroom,
basement). Conclusions: We discuss the potential implications of exposure for children's learning and
health.

6 - Associations of Early Life Water and Dietary Arsenic Exposure With Subsequent Growth
and Neurodevelopment

Kathryn Cottingham1; Diane Gilbert-Diamond1; Susan Korrick2; Margaret R. Karagas1
1Dartmouth College; 2T.H. Chan Harvard School of Public Health

Background: Exposure to high doses of arsenic via contaminated drinking water adversely impacts child
growth and neurobehavioral development. However, less is known about the effects of lower doses of
arsenic exposure typical of U.S. populations, which occur primarily through food instead of drinking
water. Aims: To assess (1) diet and water as sources of arsenic exposure in pregnant women and their
children and (2) the relation of early life arsenic exposure with subsequent growth and
neurodevelopment. Methods: The New Hampshire Birth Cohort (NHBC) study enrolls women during
the 2nd trimester of pregnancy. We evaluate arsenic exposure in mothers and children via drinking
water and diet using urinary and toenail arsenic biomarkers. We then evaluate how those biomarkers
are related to the children's altered growth and adiposity (weight, height, body mass index, waist
circumference, skinfold thicknesses) and neurodevelopment (behavior impairments, cognitive
decrements, motor proficiency alterations and deficits related to autism spectrum disorders). Progress:

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Approximately 1500 pregnant women have enrolled in the NHBC to date and ~15% have private wells
with arsenic concentrations above the current maximum contaminant level of 10 ng/L. Dietary analysis
suggests that arsenic exposure via breastmilk and typical formula during the first year of life is low
unless formula is mixed with arsenic-contaminated water, and that rice cereal at weaning is a significant
exposure pathway. Maternal second trimester urinary arsenic is associated with altered birth outcomes.
Analyses of the relation of arsenic exposure with postnatal growth and neurobehavioral development
through age 5 years are underway.

7 - Elemental Signatures in Infant Urine Reflect Dietary Patterns

Kathryn Cottingham; Kassaundra L. Amann; Tracy Punshon; Brian P. Jackson; Margaret R. Karagas
Dartmouth College

Background: Understanding low-level metal exposure during early infancy is important given the
heightened vulnerability of neonates to environmental toxins. Although previous research has reported
that powdered formulas have higher levels of both essential and toxic elements than breastmilk, to date
no one has quantified whether levels for elements other than arsenic are related to increased exposure
as measured by urinary biomarkers. We hypothesized that formula-fed infants would have higher levels
of urinary arsenic for the essential and toxic elements found at higher levels in formula than breastmilk.
Aim: To quantify differences in elemental signatures in the urine of breastfed versus formula-fed infants
at 6 weeks of age Methods - We measured concentrations of essential and toxic elements in urine
samples collected as part of the New Hampshire Birth Cohort Study and used general linear models to
relate the observed concentrations to diet type (breastfed, formula-fed, or mixed-fed), taking into
account urinary dilution (as specific gravity) and potential confounders such as age and sex. Progress:
Analyses to date suggest a relationship between feeding mode and increased exposure to non-essential
elements such as molybdenum, as well as the essential elements phosphorus, potassium, and selenium.
Overexposure to some of these toxic and essential elements could impact both short and long-term
infant health, and these effects will be explored in future work.

8 - Prenatal Exposure to Phthalates and Performance on the Bay ley Scales of Infant
Development-ll in a Population of Young Urban Children

Brett Doherty'; Stephanie M. Engel1; Mary S. Wolff2

1 University of North Carolina at Chapel Hill; 'Mount Sinai School of Medicine

Background: Previous epidemiologic studies have reported inconsistent associations between prenatal
exposure to phthalates and cognitive development in young children. Methods: We recruited 404
mother-child pairs from prenatal care facilities in New York City from 1998 to 2002. We measured
concentrations of nine phthalate metabolites in maternal urine collected during the third trimester of
pregnancy. We administered the Bayley Scales of Infant Development II (BSID-II) to children who
returned for follow-up examinations at approximately 24 months. We used generalized linear models to
estimate associations between concentrations of phthalate metabolites in maternal urine and BSID-II
indices (Mental Development Index (MDI), Psychomotor Development Index (PDI)). Results: In
multivariable adjusted models, we found no associations between maternal phthalate metabolite
concentrations and the MDI or PDI overall. However, we found strong evidence of effect measure
modification by child sex. The strongest associations were found for the metabolites mono-n-butyl
phthalate, mono-isobutyl phthalate, mono-benzyl phthalate, and mono-(3-carboxylpropyl) phthalate.
Among girls, associations were generally inverse for both MDI and PDI scores, indicating poorer

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performance across multiple metabolites, with estimates equal to a ~1.5 point decline per In-unit
increase in exposure. Conversely, associations in boys for both MDI and PDI scores were generally
positive, indicating improved performance of a slightly smaller magnitude (~1 point increase in score per
In-unit increase in exposure). Conclusions: We found evidence of associations between prenatal
phthalate exposures and child neurodevelopment in a cohort of young, urban children. Moreover, these
associations differed meaningfully by sex: associations were mixed among boys and often negative
among girls.

9 - Center for Child Environmental Health Risks Research: Epigenetics and Exposome
Assessment for Neurodevelopment

Elaine Faustman
University of Washington

The University of Washington's Center for Child Environmental Health Risks Research uses a risk
assessment framework to integrate laboratory research with epidemiological data collection. Much of
our laboratory research has focused on neurodevelopmental impacts of pesticide exposure. We
recently characterized epigenetic outcomes following exposure to arsenic and chlorpyrifos in a human
neuroprogenitor cell line during proliferation and differentiation. We found that proliferation and
differentiation status influence histone modification and methylation patterns, suggesting important
changes in susceptibility across the lifestage. In our field studies, we have assessed social determinants
of health and multiple contaminant exposures, including 87 pesticides, 22 metals and 18 phthalates. We
found that hair Cortisol concentrations varied by season and were negatively correlated with
income. Pesticide exposure varied between seasons and years and was reflective of annual use
statistics. Concentrations of pesticides measured in dust were significantly correlated to concentrations
of metabolites in urine, however, this relationship was dependent on occupational status (farmworker
or nonfarmworker) and lifestage (adult or child). Overall, this Center has leveraged laboratory analyses
of epigenetic mechanisms to understand the implications of seasonal exposure to over 100
contaminants of interest to child health and wellbeing.

10 - Spreading the Word: Home Visits Reduce Indoor Triggers and Improve Asthma Control

Lisa Gilmore; Allison Robinson
The Cadmus Group, Inc.

Home visits for asthma are an effective but underutilized intervention. Strong evidence shows that
home visits for children and adolescents that address asthma triggers in the home, such as mold and
dust, through environmental assessment, education, and remediation can significantly reduce asthma
symptoms, missed school days, and costly hospitalizations and emergency department visits.
Approximately seven million children in the United States have asthma, a common chronic childhood
disorder and a leading cause of school absenteeism. The indoor environment, especially the home
environment, is a key contributor to poor asthma control and disparities in asthma outcomes. The
Cadmus Group has been promoting in-home interventions as a way to identify and then mitigate
environmental asthma triggers for more than a decade. In 2006, Cadmus launched the Asthma Change
Campaign for U.S. EPA to promote management of environmental asthma triggers as standard medical
practice and to support the emergence of comprehensive community-based asthma care systems.
Today, the campaign's AsthmaCommunityNetwork.org engages almost 3,500 members across more
than a 1,000 programs to provide real-time access to cutting-edge tools to facilitate collaboration,

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problem solving, and learning among leaders of asthma programs; and the most current strategies for
making your program a thriving and comprehensive asthma management resource. To date,
AsthmaCommunityNetwork.org has hosted more than seven popular webinars on asthma home visits
attracting an average 250 attendees each. With rapidly growing interest among asthma programs
looking to secure sustainable financing for their home visit services, the site recently expanded to
include tools and resources on funding opportunities.

11- Children's Health and Air Pollution Study in the San Joaquin Valley—the UC Berkeley-
Stanford CEHC

5. Katharine Hammond; G Shaw; J Balmes; K Nadeau; E Eisen; J Mann; J Capitman; A Padula; K
Zografos; J Kwon; Jenny Sakar; E Noth; F Lurmann

University of California, Berkeley

The UC Berkeley-Stanford Children's Environmental Health Center is studying the relationship between
air pollution in the Californian San Joaquin Valley and children's health. The health effects upon which
we are focused include 1) preterm birth and birth defects, 2) allergic diseases and immunologic impacts,
and 3) obesity and glucose dysfunction. The poster will highlight projects 1 & 4 and the COTC. An
analysis of the relationship between PAH during several periods during pregnancy with categories of
gestational age at birth found associations between PAH during the last 6 weeks of pregnancy and birth
at 20-27 weeks (OR=2.74; 95% CI: 2.24-3.34) comparing the highest quartile to the lower three
quartiles. An analysis of Air Pollution, Neighborhood Socioeconomic Factors, and Neural Tube Defects is
reported in an accompanying poster. The fourth project, with Fresno State, developed methods to
compare structured social observation of indicators of order and disorder for walking and institutions
and began walking surveys in 10 routes in 3 zip codes; preliminary data underscore variability among
neighborhoods much greater than reported by CES Deprivation Score. The real time concentrations of
PM2.5, ultrafine particle number, black carbon, particle-bound PAHs were measured on these same
routes and compared with stationary monitors that measured continuously in Fresno Air Monitoring
Sites. The COTC completed a field project where students from an environmental science program at a
science & technology high school carried pollution monitors, GPS devices and activity monitors while in-
transit. Students mapped concentrations to learn about spatial and temporal variations in transit-related
exposures.

12 - Spatial and Temporal Trends in Traffic-Related Air Pollution from 1990 to 2015 in
Fresno, California

S. Katharine Hammond'; Elizabeth M. Noth1; Jay mi n Kwon2; Fred W. Lurmann3; Hilary A. Minor3;
David Vaughn3; Charles Perrino1

1 University of California, Berkeley; California State Univeristy, Fresno; 'Sonoma Technology, Inc.

Nitrogen dioxide (N02) and nitrogen oxides (NOx) are air pollutants that are associated with numerous
adverse health effects. N02 and NOx are used as markers for combustion, especially traffic-related
exposures. To evaluate the spatial and temporal changes in N02 and NOX, we examined data from
spatial sampling in 2002-2003 and in 2014-2015, as well as continuous fixed site monitoring from 1990
to 2015 in Fresno. N02 was measured using a chemiluminescent monitor (CM) from 1990 to 2015 at a
centrally located air monitoring station. In 2002-2003, we collected N02 and NOX by CM at 4 routine
and 9 school sites. In 2014-2015, N02 and NOX were collected by CM at 4 locations and with passive
Ogawa samplers at 50 locations for three 4-day periods. N02 collected at the central site exhibited a

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statistically significant trend in annual median concentration of -2.3% from 1990 to 2015. In 2002-2003
spatial sampling, we did not see a wide variation in N02 or NOX concentrations across Fresno. The mean
24-hr range for N02 during the cool season (October-March) was 15-26ppb, an approximate 2-fold
spatial variation. In 2014-2015, we also observed a 2- to 3-fold range in the N02 in November 2014 and
December 2014. We also compared the N02 model built from 2002-2003 data with the N02
concentrations observed in 2014-2015. In conclusion, while we observed decreasing annual trends in
the N02 concentrations from 1990-2015, we saw slightly wider spatial variability in our 2014-2015 data.

13 - Application of Citizen Science Risk-Communication Tools in a Vulnerable Urban

Community

Darryl B. Hood'; Yuqin Jiao1; Julie K. Bower1; Wansoo lm3; Nicholas Basta1; John Obrycki1;
Mohammad Z. Al-Hamdan4; Allison Wilder1; Claire Bollinger1; Tongwen Zhang1; Luddie Hatten Sr.2;
Jerrie Hatten2

1The Ohio State University; 2Stambaugh-Elwood Citizens for the Environment; 3VERTICES;
^Universities Space Research Association at NASA Marshall Space Flight Center

A citizen science-geographical information systems (SC-GIS) demographic, environmental, health status
portal was developed for the Stambaugh-Elwood (SE) community in Columbus, OH. We hypothesized
that soil at SE residences would have metal concentrations above natural background levels. Three aims
were developed that allowed testing of this hypothesis. Aim 1 focused on establishing partnerships
between academia, state agencies and communities to assist in the development of a community voice.
Aim 2 was to design and conduct soil sampling for residents of the SE community. Aim 3 was to utilize
our interactive-customized portal as a risk-communication tool by allowing residents to upload sampling
results toward educating themselves as to the potential risks from industrial emissions in close proximity
to their community. Multiple comparisons of means was used to determine differences in soil element
concentration by sampling location at P<0.05. The results demonstrated that 8-metals (As, Cd, Cu, Pb,
Mo, Se, Tl, Zn) occurred at statistically significant greater levels than natural background levels but most
were below risk-based residential soil screening levels. Results were conveyed to residents via an
educational, risk-communication informational card. SE residents also utilized the USEPA EJSCREEN tool.
The SE EJ index for zip code 43207 was found to approach the US 80th percentile in five of seven
categories signaling that the SE community is likely vulnerable to environmental impacts. This study
demonstrates that community led coalitions in collaboration with academia and local state agencies can
effectively address environmental concerns.

14 - Exposure to Benzo(a)pyrene Confers Enhanced Susceptibility to Bacterial Infection:

Validation of Research Trajectory One for the Public Health Exposome Framework

Darryl B. Hood1,3; Ryan S. Clark'; Samuel T. Pellom1,2; Burthia Booker1; Aramandla Ramesh1,2;
Tongwen Zhang3; Anil Shanker1,2; Mark Maguire1; Paul D. Juarez1; Patricia Matthews-Juarez1;
Michael A. Langston4; Maureen Y. Lichtveldg5

1Meharry Medical College; 2Vanderbilt University; 3The Ohio State University;4University of

Tennessee; 5Tulane University

The goal of this study was to validate the basic science research trajectory of our recently described
Public Health Exposome framework. This was accomplished in 2 aims designed to examine the resulting
effects of exposure on CD32-lipid raft interactions in the regulation of IgG binding to CD32. Aim 1
interrogated the effect of exposure on the fundamental requirement for activation of macrophage

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effector functions. FcyRlla (CD32a), has been reported to preferentially bind to IgG within lipid rafts. Aim
2 interrogated exposure-induced insult on CD32-lipid raft interactions in the regulation of IgG binding to
CD32. The results describe a mechanism(s) for B(a)P-exposure induced suppression of macrophage
function. We demonstrate that exposure of macrophages to B(a)P alters lipid raft integrity by decreasing
membrane cholesterol by approximately 25% with a concomitant increase in CD32 into non-lipid raft
fractions. This diminution in membrane cholesterol and 30% exclusion of CD32 from lipid rafts
effectively causes a significant reduction in CD32-mediated IgG binding to ultimately suppress critical
effector functions in the macrophage. These results offer a molecular level mechanism that is
particularly relevant to critical windows of development in a number of organ systems (central nervous
system, reproductive and particularly immune). Such exposures have the capacity to result in
suppression of macrophage effector function by disrupting lipid raft integrity to result in reduced IgG-
CD32a binding to possibly induce an immunosuppressive endo-phenotype likely leading to a subset of
disparate health outcomes that are observed in vulnerable populations.

15 - The Children's Environmental Health and Disease Prevention Research Center

Margaret Karagas
Dartmouth College

The Center's core purpose is to identify and address key emerging issues related to health impacts of
early life environmental exposures on children. Our Center builds on a model of quantifying in utero,
infant and childhood exposure to environmental contaminants, their mechanisms of action, and adverse
health impacts in a US population. Our ultimate goal is to translate these findings into public health and
clinical practice change, and policies to mitigate harmful exposures. Highlights of the year include
findings elucidating the sources of arsenic exposure among infants; use of placental tissue as a
biomarker of arsenic exposure and for assessing the impact of arsenic on mechanistic outcomes such as
placental DNA methylation; interaction of methylmercury and arsenic on cord blood methylation; and
fetal growth and developmental gene expression changes related to in utero arsenic exposure. New
clinical outcome data on increased infant infections and respiratory symptoms associated with in utero
arsenic exposure over the first year of life in a US population were published this past year that parallel
more highly exposed populations from Bangladesh. We presented to the FDA Food Advisory Committee
regarding susceptible populations and assisted in drafting legislation that would require the FDA to
regulate arsenic in rice and rice products. We produced an interactive web tool on drinking water and
dietary sources of arsenic exposure that communicated recommendations on reducing exposure and
published these recommendations in the Journal of Pediatrics and other sources to reach pediatric
health care providers as well as researchers.

16 - Residential Use of a Pyrethroid Pesticide and Facial Paresthesias in a Toddler

Catherine Karr1; Alexandra Perkins'; Frederick Walters2; Jennifer Sievert3; Blaine Rhodes3;
Barbara Morrissey3

^University of of Washington/Northwest PEHSU; 2Bainbridge Pediatrics/Northwest PEHSU;
3Washington State Department of Health/Northwest PEHSU

In this report, we document a 13-month-old healthy male who presented to his primary care
pediatrician with symptoms of facial paresthesias after a period of exposure to a consumer home-use
insecticide. History taking revealed that the interior of the house had been recently sprayed with a
product containing a combination of pyrethroids. Consultation with the Northwest Pediatric
Environmental Health Specialty Unit (PEHSU) raised suspicion that the symptoms reflected pesticide

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toxicity, given the evidence for related findings in occupational settings. Urinary metabolite testing
confirmed elevated concentrations of pyrethroid metabolites during but not after the symptomatic
period. Approximately two weeks after initial symptom onset, the home was cleaned to remove
residues and symptoms resolved. This case underscores the importance of environmental history taking
in the recognition and management of pediatric pesticide toxicity and the potential for pediatric
pesticide related illness from the widely used pyrethroid class of insecticides.

17 - Cancer Free Economy Network

Rachel Locke; Nsedu Obot Witherspoon; Polly Hoppin; Fred Brown
Children's Environmental Health Network

The Cancer Free Economy Network (CFEN) is a network of diverse organizations and funding partners
working to achieve an ambitious overall goal: "Within a generation, we (CEFN) will lift the burden of
cancers and other diseases by driving a dramatic and equitable transition from toxics to effective clean
and safe alternatives." Founded in 2014, the CFEN is developing a strategic plan, using a systems map
built by participants to describe the dynamics among institutions/sectors/organizations/interests that
influence the existence and impacts of toxic chemicals in the economy, to achieve this goal. The CFEN
includes working groups organized around certain areas of the systems map - called clusters, or areas of
capacity, called hubs. These working groups strive to: promote prevention of cancer and other diseases
caused by chemical exposures; shift the supply and demand chains to safer chemicals and safer jobs;
create diverse, "non-traditional" partners, holding equity as a highest-order principle; and develop
interconnected communications, popular education, organizing, policy and fundraising strategies. This
poster will highlight a specific cluster and portion of the larger systems map - the health cluster. The
goal of the health cluster, within the overall goal, is to: "Contribute to a national effort to eliminate
exposure to toxics to prevent cancer and other chronic diseases and promote healthy and healing
environments, particularly for overburdened and vulnerable populations (such as children), by
expanding the focus of all health-related organizations to include an understanding of the role of
chemicals in contributing to the disease process, and a commitment to promoting primary prevention."

18 - The Effect of Maternal Prenatal Diet on the Six-Week Infant Stool Microbiome
Depends on Delivery Mode

Sara Lundgren1; Juliette C. Madan1; Jennifer A. Emond1; Hilary G. Morrison2; Mitchell L. Sogin2;
Brock C. Christensen1; Margaret R. Karagas1; Anne G. Hoen1

'Dartmouth College;2Josephine Bay Paul Center, Marine Biological Laboratory

Background: Emerging evidence supports diet's strong influence on the human gut microbiome, and of
the microbiome on health, notably immune-mediated conditions. Maternal diet during pregnancy and
lactation has been associated with childhood allergy risk, but the contributing mechanisms remain
incompletely characterized. One possible link between maternal diet and infant health is through
delivery, where the infant acquires maternal gut microbes. We seek to examine the effect of maternal
prenatal diet on the infant gut microbiome at 6 weeks of age. Methods and Results: We used 16S V4-V5
targeted sequencing to examine the microbial composition of 148 6-week-old infant stool samples from
the New Hampshire Birth Cohort Study, and a food frequency questionnaire to assess maternal diet.
Microbial community structure based on generalized UniFrac distances was related to maternal prenatal
diet only in delivery mode-stratified analyses. We adjusted for delivery mode, feeding method, maternal
BMI, parity, and batch. Maternal fruit consumption in the vaginal delivery group (p=.02), and dairy in the

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cesarean delivery group (p=.04), were associated with infant stool microbiome composition at 6 weeks.
Analyses excluding antibiotic-exposed infants show the same trend, but the cesarean stratum-dairy
association was no longer statistically significant after adjustment. Conclusions: Maternal diet during
pregnancy is associated with the 6-week infant intestinal microbiome differentially by delivery mode;
the observation of an effect in both delivery mode groups suggests multiple routes of influence for
maternal diet on the infant gut microbiome.

19 - Healthy Eating Better Breathing: A Dietary Intervention Study in Asthma

Meredith McCormack
Johns Hopkins University

Rationale: Observational evidence suggests a Mediterranean-like diet may improve asthma health. We
conducted a randomized, crossover dietary intervention study to assess the impact of Mediterranean-
like, healthy diet on asthma outcomes and to determine feasibility of a larger scale dietary trial in
asthma. Methods: Participants with doctor-diagnosed asthma were randomized to initially receive a 4-
week dietary intervention or to continue their usual diet. After a 4-week washout, participants received
the alternate assignment. In the intervention arm, participants ate 3-5 meals per week on site at the
Johns Hopkins ProHealth Research Center in Baltimore, MD. All remaining meals and snacks were
provided by the study for participants to consume off-site. Asthma clinical outcomes and biomarkers
relevant to asthma and dietary intake were assessed at 0, 2, and 4 weeks after starting each treatment.
Results: Seven participants completed the study protocol. The average age was 42 years, six
participants were female, and six were African American. Serum carotenoids (lutein, alpha carotene,
retinyl palmitate), biomarkers assessing adherence to the intervention, increased in the intervention
versus control (p<0.05) (Figure 1). Asthma Control Test Scores and lung function (FEV1/FVC) tended to
improve with intervention versus control diet although results did not reach statistical significance.
There was no difference in change in exhaled nitric oxide between intervention and control.
Conclusions: The findings from this randomized, crossover study suggest that a dietary intervention trial
in participants with asthma is highly feasible and findings support the need for a larger, future study to
determine the effect of a healthy dietary intervention on asthma symptoms and lung function.

20 - Two Contemporary Sources of Child Lead Exposure: Resuspended Soil and Avgas

Shawn McElmurry1; Sammy Zahran2; Terrence Iverson2; Stephan Weiler2
1 Wayne State University; 'Colorado State University

Historical sources of Pb to the environment include leaded gasoline, paint and solder. The quantity of Pb
entering the environment from these sources has greatly diminished; yet, legacy contamination in soils
continues to be a source of exposure. Currently, in the United States, over half of the Pb discharged into
the atmosphere is attributable to lead-formulated aviation gasoline (avgas). In this study we evaluate
the impact of two of these contemporary sources of Pb exposure: resuspended soil and avgas. To
evaluate exposure from resuspended soil and Pb aerosols, the blood lead levels (BLLs) of 367,839
children (ages 0-10) in Detroit, Michigan USA were analyzed from 2001 to 2009. A 1% increase in the
amount of resuspended soil results in a 0.39% increase in the concentration of Pb in the atmosphere
(95% CI, 0.28 to 0.50%). Resuspended soil was found to be a significant underlying source of
atmospheric Pb and explain age-dependent variation in child BLLs. Next, the BLLs of 1,043,391 children
living near 448 airports in Michigan were evaluated over time and compared to the volume of piston-
engine aircraft traffic that utilize avgas. Based on our analysis, we find that child BLLs: 1) increase dose-

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responsively in proximity to airports, 2) decline measurably among children sampled in the months after
9-11, 3) increase dose-responsively in the flow of piston-engine aircraft traffic, and 4) increase in the
percent of prevailing wind days drifting in the direction of a child's residential location. Overall, leaded
avgas contributes significantly to child BLLs near airports.

21 - Center for Integrative Research on Childhood Leukemia and the Environment
(CIRCLE)

Catherine Metayer

University of California, Berkeley

Background: The etiology of childhood leukemia (CL) involves the interplay of environmental, genetic,
and epigenetic factors. PROJECT 1 Aim: To assess the association between chemical exposures and CL
subtypes. Methods: We combined data for ~9,000 acute lymphoblastic leukemia (ALL), 1,300 acute
myeloid leukemia (AML), and 15,000 controls from the Childhood Leukemia International Consortium.
Results: We strengthened evidence of modest and/or dose-dependent relationships between paternal
smoking, and exposure to paints and pesticides. The magnitude of the associations varied by ALL, AML
and the presence of chromosome abnormalities. A new finding suggested an association between
maternal smoking during pregnancy and AML among Hispanics only. PROJECT 2 Aim: To compare fetal
exposures between ALL cases and matched controls. Methods: We employed untargeted liquid
chromatography-high resolution mass spectrometry of small molecules in neonatal blood spots from
100 ALL cases and 100 matched controls. Results: We detected small-molecule features that
discriminate between ALL cases and matched controls. PROJECT 3 Aim: To determine the relationship of
cigarette smoking to DNA methylation changes in CpG loci that contribute to leukemogenesis. Methods:
We characterized DNA methylation patterns in neonatal blood spots from 397 CL cases and 439 controls
by reported smoking status, accounting for DNA methylation in blood cell types. Results: Several of the
CpG sites that we found previously to contribute to leukemogenesis were also sensitive to cigarette
smoking. Conclusions: We will continue working to identify in utero chemical risk factors for CL, and to
understand how these chemicals increase risk via immunological, genetic and epigenetic mechanisms.

22 - Increasing Environmental Health Literacy via A Story of Health Multimedia eBook and
CE Course

Mark Miller1,2,3; Maria Valenti4; Ted Schettler5; Vickie Leonard'

1 Western States PEHSU (at UCSF);2CIRCLE at UC Berkeley; 3Cal EPA; 4Collaborative on Health and
the Environment; sScience and Environmental Health Network

Background: In recent surveys pediatricians agree that children suffer preventable illnesses of
environmental origin but feel ill-equipped to educate families about common exposures. Narrative
approaches are emerging as powerful health promotion tools that can increase understanding of
determinants of health and translate complex science. Objective: A Story of Health multimedia eBook
and continuing education (CE) course were designed to harness the power of storytelling to improve
environmental health literacy for health professionals and others. Methods: The peer-reviewed eBook
uses fictional stories to convey how multiple environmental factors affect health across the lifespan,
encourage inclusion of anticipatory guidance, and stimulate policy changes. Readers can explore risk
factors for asthma, developmental disabilities and childhood leukemia. Each story features the latest
research about disease origin and prevention and examines how our natural, built, chemical, food and
socioeconomic environments interact with our genes to influence health. We have drawn content from

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the collective expertise of the PEHSU network and the NIEHS Children's Centers, among others. Each
story is enriched with illustrations, videos, and links to hundreds of online resources and references.
Free CE's are offered through the CDC. Results and conclusions: The eBook provides an alternative
method of developing competency in environmental health, as it can be accessed online and reviewed
at an individual's time and pace. Over 1000 health professionals have already registered for the course.
In recent evaluations, 90% say they will be able to apply what they learned from the eBook to their
practices and provide intervention strategies to patients.

23 - Mass Cytometry Identifies Unique Monocytes and T-cell Alterations After Pollution
Exposure

Hua Fan-Minoguel; Kan Nadeau
Stanford University

Short-term and long-term air pollutant exposures are linked with adverse health outcomes; however,
how they affect immune responses and contribute to disease pathogenesis remains unclear. We tested
whether air pollution modulates multiple immune cell subsets in subjects with and without underlying
disease. Using a single-cell mass spectroscopy-based flow cytometry, we studied blood samples from
four groups: healthy controls with low- vs. high-polluted environments (LPE vs. HPE) and asthmatic
subjects with LPE vs. HPE. Seven ambient air pollutants (AAPs) were simultaneously measured at short-
term (< 6 month) and long-term (> 6 month) exposure periods in HPE groups. In healthy subjects, we
found that HPE is associated with significant increases of innate lymphoid type 2-like cells (ILC2-like) and
decreases in CD8+ T-cells and tetanus vaccine responses. In asthmatic subjects, alterations in immune
cells by HPE were dramatically affected by disease status with significant increases in "alternative"-
monocytes and activated CD4+T-cells and decreases in "classical"-monocytes and B-cells. In summary,
these findings indicate that, in healthy individuals, AAP could begin to skew the immune system towards
atopy and diminished immunity. Additionally, having underlying asthma could significantly worsen AAP-
associated innate and adaptive immune responses leading to further pathogenesis and exacerbation of
disease.

24 - Predictors of Urinary Cadmium Among Mothers and Children in Mexico City

Meghan Moynihan1; Karen E. Peterson1; Alejandra Cantoral2; Peter Song1; Nil Basil'; John Meeker1;
Martha Maria Tellez-Rojo2

1 University of Michigan; 2Nationat Institute of Public Health

Cadmium is a naturally-occurring heavy metal with anthropogenic activities contributing to the
contamination of agricultural land. Most relevant non-occupational exposures include tobacco and diet.
Exposures, both acute and chronic, have been associated with adverse health effects including renal and
bone, cardio-metabolic, and cancer. Urinary cadmium (UCd) is measure of long-term exposure used to
assess cadmium exposure in epidemiological studies. Estimated dietary cadmium (DCd) has similarly
been used in studies, the validity of which is disputed. This study aimed to describe the distribution of
UCd; quantify DCd estimated from food frequency questionnaires; and determine the relationship of
DCd and UCd, among other predictors of UCd in mothers and their children in a well-characterized
Mexico City birth cohort. 214 third trimester maternal urines and 250 child urines were analyzed for
cadmium. The analytic sample was limited to 192 mothers and 223 children based on availability of DCd
(primary exposure), UCd (outcome), maternal history of smoking, and significant covariates. UCd was
specific-gravity corrected and log transformed; DCd was energy adjusted using the residual method.

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Linear regression models showed a positive association between DCd and UCd among mothers and
children without a maternal history of smoking, adjusted models (3=49.76, p-value=0.03 and (3=26.12, p-
value=0.03, respectively. Other significant covariates include age and BMI: age was positively associated
in mothers with a smoking history ((3=0.031, p-value=0.03) and BMI was negatively associated in
children without a maternal smoking history (|3=-0.098, p-value=0.049). Diet is an important source of
cadmium exposure among nonsmoking mothers and their children in Mexico City.

25 - Neurodevelopment and Improving Children's Health Following Environmental
Tobacco Smoke exposure (NiCHES)

Susan Murphy; Scott Kollins; Bernard Fuemmeler; Cathrine Hoyo; Edward Levin; Theodore Slotkin;
Fred Seidler; Lisa Satterwhite; Brandon Hall; Joseph Lucas; Michele Taylor; Rochelle Schwartz-
Bloom; Kathryn Pollak; Paul Bloom

Duke University

NiCHES is determining how epigenetic mechanisms are altered by early life environmental exposures
and how this affects later neurodevelopmental outcomes. Project 1: We conducted deep
neurodevelopmental phenotyping on ~190 children-mother dyads. We implemented our new cohort
management platform that sends automated text, interactive voice response and emails to enhance
engagement, conduct ecological momentary assessments, and facilitate retention. Recruitment will
continue through 2016 followed by a second assessment of participants. Project 2: Early exposure of
rats to tobacco smoke extract (TSE) causes more pervasive neurobehavioral impairments than does
nicotine. Behavioral effects include adolescent locomotor hyperactivity and impaired cognitive
performance. Early life TSE exposure disrupts neural systems involved with cognition and locomotor
activity; cholinergic and serotonergic systems were more disrupted in rats exposed to TSE than nicotine.
Similar enhanced damage with TSE was seen in in vitro models. Project 3: gDNA and RNA from rat
frontal cortex, hippocampus and blood are ready for generation of WGBS and transcriptome data to
identify responsive loci showing correlations with expression and the same epigenetic changes in
peripheral blood. COTC: We field tested an educational brochure and website on exposure of pregnant
women to secondhand smoke and risk of ADHD in their children. A public Instagram contest was held to
view the brochure and website and submit images depicting the message to help babies avoid smoke.
We will conduct a public field-test to determine social media most likely to engage the public to learn
more about the effects of secondhand smoke and risk of ADHD.

26 - Traffic-Related Air Pollution, Neighborhood Socioeconomic Factors and Neural Tube
Defects in the San Joaquin Valley of California

Amy M. Padula

Stanford University

Neural tube defects, including spina bifida and anencephaly, are one of the most common types of birth
defects. Environmental pollutants and socioeconomic factors have been associated with neural tube
defects. The potential impact of interaction between ambient air pollution and neighborhood
socioeconomic factors on the risks of neural tube defects is not well understood. We investigated
whether associations between traffic-related air pollutant exposure in early gestation and neural tube
defects were modified by neighborhood socioeconomic factors in the San Joaquin Valley of California,
1997-2006. Five pollutant exposures, three outcomes and 9 neighborhood socioeconomic factors were
included for a total of 135 investigated associations. Estimates were adjusted for maternal race-

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ethnicity, education, body mass index and multivitamin use. We present below odds ratios whose
accompanying confidence intervals do not include 1 and a chi-square test of homogeneity p-value <0.05.
We observed increased odds of spina bifida comparing the highest to lowest quartile of PM<10
micrometers (PM10) among those living in a neighborhood with: a) median household income of less
than $30,000 per year (OR=3.9; 95% CI: 1.3, 12.1); and b) more than 30% with less than or equal to a
high school education (OR 2.7; 95% CI:1.1, 6.2). Among women who lived in higher SES categories, there
was no association between PM10 and neural tube defects. When analyzing both case types together,
these odds were attenuated. Our results demonstrate effect modification by neighborhood
socioeconomic factors in the association of fine PM and spina bifida in California.

27 - Biorepository at Dartmouth: A Resource for Children's Environmental Health and
Disease Prevention

Thomas Palys; Marsit, C.J.; Wells, W. A.; Karagas, M.R.

Dartmouth College

The Biorepository at Dartmouth involves a combination of manual and advanced robotic liquid handing
processes, as well as traditional and state-of-the art automated archival storage strategies (e.g. ambient
temperature, 4°C, -20°C, -80°C, and liquid nitrogen) to support the Children's Environmental Health and
Disease Prevention Research Center at Dartmouth and other members of the Dartmouth research
community. The Biorepository encompasses a broad range of subject ages and specimen types, i.e.,
blood and its components, urine, nails, meconium, stool, placenta, breastmilk, DNA and RNA, as well as
various environmental samples. Services include blood fractionation, lymphocyte isolation, aliquoting of
specimens into various storage formats, human and microbiome nucleic acid extraction, quantification
and normalization, tissue separation and fixation, specimen retrieval, shipping and referral management
services and individual consultation for study design and execution. Comprehensive specimen
management is tracked using eVelos-eSample software, with capabilities of linkage to and querying of
archival databases in i2B2. Since its inception in 2013, the Biorepository has processed over 14,000 adult
and infant specimens and archived over 80,000 aliquots, many of which are being stored in robotic
freezers. Additionally, the Biorepository manages the Dartmouth Biospecimen Storage Facility, a secure,
off-site facility dedicated to long term storage of specimens, with real-time video surveillance,
continuous and redundant monitoring of freezer temperatures and emergency response to users. The
availability of environmental and biologic samples that can be efficiently processed and retrieve can
dramatically advance the pace at which high dimensional and other analyses can be performed, and
provide critical information on children's health.

28 - Imaging the Placental Metallome in the New Hampshire Birth Cohort

Punshon, T.1; Jackson, B.P.1; Ornvold, K.2; Marsit, C.J.1; Karagas, M.K.1
1 Dartmouth College; 'Dartmouth Hitchcock Medical Center

Background: Metal contaminants readily cross the placenta, potentially having tangible effects on
growth, development and lifelong health. Toxicant metals are recognized as targets by transporters for
biologically essential mineral nutrients. We use elemental imaging to characterize genes encoding
membrane-bound metal transporters in biological tissue. In many cases, the spatial location of an
element overlaps with expression of the gene encoding for the responsible membrane-bound
transporter. We extended our approach to the human placenta, an organ where controlled,
bidirectional membrane transport mediates all of the nutrient, waste and gaseous transport between

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mother and fetus. Aims: To understand maternal-fetal transfer of metal(loid)s and mineral nutrients
across human placenta, particularly metal-nutrient interactions, relationships with other biomarkers of
metal exposure. Methods: We collected multi-element profiles from >750 placental biopsies from
women enrolled in the New Hampshire Birth Cohort Study, a study initiated to study the effects of
drinking water arsenic on infant health. We compared this to maternal and infant toenail metal
concentrations. We developed methods for elemental imaging of placenta via Synchrotron X-Ray
Fluorescence, as well as multi-elemental approaches for both spatial analysis and speciation using laser
ablation and liquid chromatography-ICP-MS. Results: Metal(loid) toxicants are readily transported
across the human placenta. Arsenic levels in placenta correlate with levels of arsenic in maternal urine,
maternal nails, infant nails and household drinking water. Conclusions: Evaluating the placental
metallome as part of a large-scale epidemiologic study provides novel insights into early life
environmental determinants of children's health, and the function of the human placenta.

29 - Break the Cycle of Environmental Health Disparities in Vulnerable Children

I Leslie Rubin1,2,3,4; Robert J Geller2,5; Kurt Martinuzzi2,6; Maeve Howett2,6; Benjamin A Gitterman7;
L Laura Wells1,2; Joav Merrick8,9,10,11,12

'Innovative Solutions for Disadvantage and Disability;2Southeast PEHSUf Emory University;
3Morehouse School of Medicine; 4Developmental Pediatric Specialists; sGeorgia Poison Center;
6Emory University; 7George Washington University; ^National Institute of Child Health and Human
Development, Israel; 9Ministry of Social Affairs and Social Services, Israel; 10Hadassah Hebrew
University Medical Center; "Kentucky Children's Hospital; 12Georgia State University

Children who grow up in circumstances of social and economic disadvantage are at greater risk for
exposure to adverse environmental factors and are more likely to suffer consequent adverse health and
developmental outcomes. Break the Cycle supports a set of student driven research projects that
creatively explore the environmental and social factors that adversely affect children's health and well-
being and develop creative ways to Break the Cycle. Students work with their academic mentors and the
Break the Cycle team to complete their projects for presentation at an annual conference with other
students from around the country and internationally. They then write up their projects for publication
in an international peer-reviewed journal. To date, Break the Cycle has partnered with over 30 different
university departments in 9 States in the USA and internationally, worked with over 90 students and
published 7 monographs and 6 themed books of the student projects. A survey of past students found
that they rated their experience with Break the Cycle valuable in: conducting a research project,
presenting at a conference and having a publication; many reported that they continued to pursue
career interests related to their work on the Break the Cycle projects. We propose that the Break the
Cycle Program is a cost effective way of raising awareness of environmental health disparities among
university students in their early years, encouraging their involvement in the field of children's
environmental health and environmental health disparities, and cultivating their potential for future
leadership in the field.

30 - New Findings from the Illinois Children's Center: Spotlight on BP A

Susan Schantz
University of Illinois

The Children's Environmental Health Research Center at Illinois studies the impact of endocrine
disrupting chemicals on reproductive and neural development. The group is evaluating exposures during
the prenatal and adolescent periods, and is conducting complementary studies in animal models and

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human infants and children. Recent animal studies have yielded important new findings regarding BPA.
The Flaws' group investigated the transgenerational effect of prenatal BPA exposure on female fertility.
Pregnant mice (FO generation) were exposed to low doses of BPA (0, 0.5, 20 or 50 ng/kg), and the
fertility of female mice from the Fl, F2 and F3 generations was evaluated. BPA reduced fertility in all
three generations of mice. Strikingly, the most dramatic reductions in fertility were seen at the lowest
(0.5 ng/kg) BPA dose. The Juraska group evaluated the effect of BPA exposure during adolescence on
neuron and glia numbers in the prefrontal cortex—a brain region important for cognitive functioning.
Male and female rats were exposed to 0, 4, 40 or 400 ng/kg BPA on postnatal days 27-46. There was no
effect on neuron number, but BPA increased microglia number—the immune cells of the brain—in
females, and decreased microglia number in males. This year the Illinois COTC hosted a state-wide
conference for childcare providers. The conference increased awareness and knowledge of
environmental health issues among childcare providers, and lead to a call for the formation of a task
force to investigate alignment of childcare practices and policies with current recommendations to
protect children's health.

31 - A Blueprint for Protecting Children's Environmental Health: An Urgent Call to Action

Brianna Sleezer; Tracy Kolian; Nse Witherspoon
Children's Environmental Health Network

A historic meeting was convened by the Children's Environmental Health Network at Wingspread,
headquarters of the Johnson Foundation, in Racine, Wisconsin on October 21-23, 2014. Over 30
visionary leaders representing perspectives from academia, non-profit advocacy, environmental justice,
child health, urban planning, public health, business, economics, public policy, law, and agriculture
gathered in urgent recognition that children are increasingly suffering from an array of chronic diseases
and developmental conditions linked to environmental exposures. This diverse group of leaders drafted
a dynamic vision statement calling for transformative change through renewed and collective action to
provide all children with the protections from harm that they deserve. In the weeks following the
retreat, these leaders developed a Blueprint for Action to move the vision to reality. The
recommendations and actions outlined in this Blueprint are the framework for moving forward. This is
just the beginning. Bold and comprehensive action is necessary.

32 - UC Davis Center for Children's Environmental Health and Disease Prevention (CCEH)

Judy Van De Water
University of California, Davis

The principal goals of the UC Davis Center for Children's Environmental Health and Disease Prevention
(CCEH) are to identify and understand environmental, immunologic, and genetic risk factors contributing
to the incidence and severity of childhood autism. Currently we are: (1) Leveraging our existing studies
and biobanks for specimens to expand our research and capitalize upon the Center's research findings
to date. Through Project 1, we are cultivating our numerous resources from the CHARGE study, as well
as the epidemiological and clinical studies involving prospective parents, pregnant women and children
from the ongoing MARBLES study — both of which grew out of previous years of CCEH funding; (2)
Through Projects 2-4, we are building upon our earlier findings of calcium dysregulation in cultured
neurons and immune cells in the context of understanding the epigenetic effects and ramifications of
toxicant exposure on gene pathways and immune function. We have found that children with ASD have
a differential response to total body burden of PBDEs compared to TD controls; (3) Working to develop

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and apply new biomarkers of autism risk, through analysis of gestational immune dysfunction (Project
3), genetic susceptibility (Projects 1-4), epigenetics (Project 2), and environmental exposures (Projects 1-
4, Core C), to best characterize the potential health effects at various life stages and predict longer-term
clinical and behavioral consequences. We have defined genes associated with folate insufficiency during
conception and early gestation and how folate supplementation remediates some toxicant risks
associated with altered neurodevelopment; (5) Continue to expand the successful Community Outreach
and Translation Core (Core B) to continue the active engagement of our ASD families, as well as the
California Department of Health Services and the broader cross-cultural community in the research
process, and the translation and application of our research findings. We have liaised with the CAL-EPA
on assessment of global warming on children's health.

33 - Story of Health Multi-Media eBook—Storytelling to Translate Science for Health
Promotion and Disease Prevention. The Next Installment: Infertility

Mary a Zlatnik1; Mark Miller'; Ted Schettler2; Brian Tencza3; Maria Valenti4

'University of California, San Francisco PEHSU; 2Science and Environmental Health Network;
iATSDR; 4Collaborative on Health and the Environment

Narrative approaches and storytelling are powerful health promotion tools that can help increase
understanding of determinants of health and translate complex science. The Story of Health multi-media
eBook capitalized on this approach by using fictional stories to help convey how environmental factors
affect health across the lifespan. The first installment, which included chapters on asthma,
developmental disabilities, and childhood cancer, has been viewed many times (see abstract ##) by
clinicians and others seeking to understand environmental determinants of these conditions. The stories
are accessible to an educated lay audience, with more technical sections for scientists and medical
professionals, who can access free continuing education credits through the eBook. A forthcoming
installment is in development, which will expand the story-telling approach to the clinical areas of
reproductive health and infertility. Reproductive health forms the substrate for later child and family
health, however environmental influences on reproductive health have long been overlooked. This
installment aims to ground the science of environmental health in stories of people struggling with
infertility. Topics included in the eBook include endometriosis, thyroid function, endocrine disrupting
chemicals, healthy eating, pesticides, and preconception health for men and women. The audience for
the new installment would include primary care physicians, obstetrician/gynecologists, nurse midwives,
other clinicians caring for patients struggling with infertility, as well as lay audiences.

34 - Low-Level of Environmental Lead Exposure and Children's Proactive Aggression

Zehang Chen; Yuli Li; Jianghong Liu
University of Pennsylvania

Background: Lead exposure has been linked to externalizing behavior including aggression in children.
However, the type of aggression was not previously reported. The aim of this study is to identify the
proactive and reactive forms of aggression in relationship to lead exposure in community children.
Methods: A population-based sample of 971 children who are part of NIEHS funded Jintan cohort study
participated in this study. Children's blood lead level (BLL) data and self-reported Reactive-Proactive
Questionnaire (RPQ) were collected at the same time with mean age 12 years old (SD=0.4). The RPQ
contains 23 items and tested two forms of aggression: proactive aggression and reactive aggression.
Generalized linear models (GLMs) with main effects and an interaction between children' sex and BLL

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were conducted to test the relationship between BLL and children's aggression, controlling for children's
residence, siblings, and parental education level and occupation. Results: The mean (SD) blood lead
concentration was 3.1 (1.2) ng/dL, with the median value being 2.9ng/dL. GLMs results showed that
boys with increasing BLL have more aggression (Ps<0.05). Children with median higher BLL
(BLL>2.9ng/dL) had more proactive aggression and total aggression (Ps<0.05). This effect is particularly
stronger for boys than girls. BLL is not significantly related to reactive form of aggression. Conclusions:
Low-level of lead exposure below 5 ng/dL with mean BLL of 3.1 ng/dL is associated with both total
aggressions and proactive form of aggression in community children. Lead exposured boys are particular
vulnerable. Further studies are needed to understand the underlines of this relationship.

35 - Children's Dietary Pattern is Associated With Blood Lead Levels

Jianghong Liu1; Zumin Shi2

University of Pennsylvania1; University of Adelaide2

Background: The role of diet has been suggested to be linked with blood lead levels (BLL). However, few
studies have assessed the type of dietary pattern. Methods: This cross sectional study is part of the
China Jintan cohort study, children's BLL and self-reported food frequency data were collected at age 12
years old (SD=0.4). Factor analysis was used to derive dietary patterns. 896 children with dietary intake
and BLL were included in the analysis. Results: In this sample, the mean BLL was 3.1(SD 1.2) ng/dL with
6.4% of children's BLL >5 ng/dL. Three dietary patterns were identified. The first pattern (snack and
drink) was characterised by unhealthy with high intake of chips, sweets, beverages and soymilk. The
second pattern had high loadings of meat and fish. The third pattern was classified as healthy with high
intake of fruit, vegetable, milk, cereal, and water. After adjusting for gender, parental education,
residence and schools, for every one standard deviation increase in the food pattern score, the
regression coefficient for BLL was -0.12(95%CI -0.22 to -0.03) for healthy pattern, 0.18(0.09-0.27) for
snack and drink pattern. The odds ratio for high BLL (>5 ng/dL) were 1, 3.26(95%CI 1.34-7.99), and
3.80(1.52-9.46) (p for trend <0.001) across tertiles of snack and drink pattern; 1, 0.43(0.19-0.95), and
0.63(0.28-1.40) (p for trend 0.405) for healthy pattern, respectively. No association between meat and
fish pattern and BLL was found. Conclusion: Healthy dietary pattern is inversely but snack and drink
pattern is positively associated with BLL among Chinese adolescents.

36 - Low Blood Lead Concentration is Associated With Sleep Disturbance in Preadolescents

Jianghong Liu; Qi Xia; Xiaopeng Ji; Linda McCauley; Alexandra L Hanlon
University of Pennsylvania

Background: We previously reported that high blood level lead exposure (>10.0 ng/dL) is related to
sleep disturbance in childhood. However, it is not known if the lead-sleep relationship is extended to low
blood level lead exposure. Methods: As part of the China Jintan Cohort Study, 806 school children had
BLL assessed at 12 years and sleep assessed around the same time using the parent-reported Child Sleep
Health Questionnaire (CSHQ). Results: Mean age of the sample at BLL and sleep assessment was 12
years old (SD =0.88). Mean BLL was 3.03 ng/dL (SD = 1.19). There were significant positive correlations
between BLL and 4 CSHQ subscales: sleep duration (r =0 012, P <0.05), bed resistance (r =0.018 , P <
0.10), sleep anxiety (r= 0.015 , P < 0.05) and parasomnia (r =0.019 , P <0.05 ). By dichotomizing BLL with
value 5 ng/dL, mean (3.03 ng/dL) and median (2.8 ng/dL) respectively, all showed positive correlations
between dichotomized BLL and total scores (r=2.218, P<0.10; r=1.331, P<0.05; r=1.163, P<0.10). The
results are controlled for parental educations, parental occupations, gender, schools and grades.

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Conclusion: Our findings indicate that even BLL at mean 3.03 ng/dL in childhood are also associated with
increased risk for sleep problems

37 - Low-Level Lead Exposure is Associated with Delayed Brain Maturation

Jianghong Liu; Yuli Li; Naixue Cui; Anna 5. Rudo-Hutt; Adrian Raine
University of Pennsylvania

Background: The effect of lead (Pb) exposure on children's brain function as measured by
electroencephalograph (EEG) is not well documented. We aim to test the hypothesis that environmental
lead exposure will be associated with increased slow-brainwave EEG (delta and theta wave) in
community children. Methods: As part of the China Jintan Cohort Study, 517 children aged 12 years
(SD=0.4) were tested for blood lead level (BLL) and EEG. Resting-status EEG (alphal, delta, and theta
wave) was recorded using an Electro-Cap with tin (Sn) electrodes. Generalized linear models (GLMs) and
repeated ANOVA analyses were conducted to test the relationship between BLL and the global resting-
status EEG power in each band, controlling for children's sex, grade, residence, siblings, and parental
marital status. Results: The mean (SD) BLL was 3.1 (1.1) ng/dL, with the median value being 2.9ng/dL.
GLMs results showed that increasing BLLs correlated with increasing global EEG Delta power (B=0.002,
P=0.002) and decreasing global EEG alphal power (B= -0.001, P=0.010). The interactions between lobes
and BLL indicated that increasing BLL were associated with increasing frontal (F4/F3) EEG theta power.
Furthermore, the repeated ANOVA analyses showed that children with relatively higher BLLs (pb> 2.9
Hg/dL) had increased delta EEG power (F(l,396) =5.74, P=0.017) in each hemisphere. Conclusion: Slow-
brainwave EEGs are usually reduced with increased age throughout childhood. Consequently, our
finding that low-level lead exposure is associated with increasing theta and delta power suggests that
even with a median BLL below 3pig/dL Pb can slow brain maturation and result in neurodevelopment
delay.

38 - Low Level of Lead Rxposure is Associated With Prolonged P300 Latency Among 12
Year Old Children

Bowen Yao; Naixue Cui; Jianghong Liu
University of Pennsylvania

Background and Objectives: Low-level lead exposure has been associated with decreased IQand
neurocognitive deficits in childhood. However, the neurophysiological mechanism underpinning these
relationships remains unknown. The present study aims to examine the association of low-level lead
exposure with P300, a positive component recorded by event related potential (ERP) as an indicator of
neurocognitive capacity in a community sample of Chinese children. Design/Methods: As a part of the
China Jintan Child Cohort Study, 327 children with mean age 12 years (SD=0.64) participated in 2012-
2013 period of data collection. Their blood lead levels (BLLs) were measured. ERPs were recorded from
Ag/AgCI electrodes using the ECI Electro-Cap System (Electro-Cap International) with International 10-20
placement sites using Biopac hardware and software in a NIEHS funded psychophysiology Lab in Jintan
Hospital in China. A standard auditory oddball task (constituted by novel, target and non-target auditory
stimuli) was used to generate P300 after stimulus presentation. The P300 amplitude and latency were
recorded. Results: The mean BLL in this sample was 3.16ng/dl (SD=1.17). Compared to those with BLLs
lower than the mean level, children with BLLs higher than the mean had prolonged P300 latency to
novel stimuli (P = 44.45, robust s.e.=19.41, p=0.02) after adjusting children's sex and paternal education
levels. Conclusion: In this population based community sample of Chinese children, BLL with mean level

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3.16|J.g/dI is associated with impaired capacity during processing of novel stimuli indicating impaired
cognitive function. The results provide important implications that early detection and intervention of
lead exposure in childhood are warranted to prevent cognitive deficits.

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2015 NIEHS/EPA Children's Centers Annual Meeting

October 29-30, 2015
Appendix D - Participant List

Margaret Adgent
NIEHS

Hayley Aja
U.S. EPA/NCER

Emanuel Alcala

California State University, Fresno/Central
Valley Health Policy Institute

Cecilia Alcala
U.S. EPA/NCEA

Kathleen A. Alexander

Virginia Polytechnic Institute and State
University

Laura Anderko

Georgetown University

Daniel Axelrad
U.S. EPA/NCEE

Claire Barnett

Healthy Schools Network

Carl Baum

PEHSU West

Britni Belcher

University of Southern California

Martha Berger
U.S. EPA/OCHP

Cassie Bernardi

American Academy of Pediatrics

Linda Birnbaum

NIEHS

Susan Blaine

ICF International

Maggie Brevile
U.S. EPA/NCER

Pat Breysse

ATSDR/CDC

Charlotte Brody

BlueGreen Alliance

Rebecca Bruhl

Baylor College of Medicine

Susan Buchanan

University of Illinois at Chicago

Michele Burgess
U.S. EPA/OSWER/OSRTI

Tom Burke
U.S. EPA/ORD

Trisha Calabrese

American Academy of Pediatrics

Rich Callan
U.S. EPA/NCER

Ryan Canavan

Georgetown University

John Capitman

Central Valley Health Policy
Institute/California State University,
Fresno

Gustavo Carlo

University of Missouri

Zehang Chen

University of Pennsylvania

Gail Christopher
W.K. Kellogg Foundation

Elaine Cohen Hubal
U.S. EPA/CSS

Diana Conway

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Jose Cordero

University of Georgia

Sadie Costello

University of California, Berkeley

Kathy Cottingham

Dartmouth College

Sally Darney
NIEHS

Diane DArrigo

NIRS

Matthew Davis
U.S. EPA/OCHP

Alexandra Davis

University of Missouri

Natasha DeJarnett

American Public Health Association

Carrie Dickenson

American College of Medical Toxicology
Greg Diette

Johns Hopkins University

Brett Doherty

UNC Chapel Hill

Dana Dolinoy

University of Michigan

Brenda Doroski
U.S. EPA/ORD

Christie Drew
NIEHS/DERT

Rebecca Dzubow
U.S. EPA/OCHP

Stephanie Engel

UNC Chapel Hill

Ruth Etzel
U.S. EPA/OCHP

Sandy Evalenko
U.S. EPA

David Evans

Columbia University

Elaine Faustman

University of Washington

Robert Felix

MotherToBaby/Organization of Teratology
Information Specialist

Timothy Fennell

RTI International

Barbara Fiese

University of Illinois at Urbana-Champaign

Michael Firestone
U.S. EPA/OCHP

Cindy Folkers

Beyond Nuclear

Stella Fonkeng

University of Maryland

Brenda Foos
U.S. EPA/OCHP

Erica Forrest

Children's Mercy Hospital

Mai da Galvez

Mount Sinai Hospital

Mary Gant
NIEHS

Laura Geer

SUNY Downstate

Andrew Geller
U.S. EPA/SHC

Heidi Gerbracht

Bright Cities

Lisa Gilmore

The Cadmus Group, Inc.

Gary Ginsberg

Connecticut Department of Public Health

AM Goldstone

ICF International

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Robert Gould

University of California, San Francisco

Natalie Grant

HHS

Kimberly Gray
NIEHS

Rachael Greenberg

National Nursing Centers Consortium

Peter Grevatt
U.S. EPA/OGWDW

Virginia Guidry

NIEHS Office of Communications

Intaek Hahn
U.S. EPA

Katharine Hammond

University of California, Berkeley

Michael Hatcher

ATSDR/CDC

Marissa Hauptman

Region 1 New England PEHSU/Boston
Children's Hospital

Julie Herbstman

Columbia University

Irva Hertz-Picciotto

University of California, Davis

Jane Houlihan

Healthy Babies Bright Futures

Valerie Hu

The George Washington University
Katie Huff ling

Alliance of Nurses for Healthy
Environments

Luz Huntington Moskos

University of Louisville

Anna Jeng

Old Dominion University

Jill Johnston

University of Southern California

Dean Jones

Emory University

Elizabeth Kamai

UNC Chapel Hill

Catherine Karr

University of Washington

Kevin Kennedy

Children's Mercy Hospital

Jina Kim

ASPPH Fellow at U.S. EPA
Sue Kirdly

Cohen Children's Hospital

Andrea Kirk
U.S. EPA/OSWER

Katherine Kirkland

Association of Occupational and
Environmental Clinics

Kristen Kocher

The George Washington University
Brenda Koester

University of Illinois at Urbana-Champaign
Susan Korrick

Brigham and Women's Hospital/Harvard
Medical School

Kim Lambert

U.S. Fish and Wildlife Service

Bruce Lanphear

Simon Fraser University

Patricia Las ley

University of Illinois at Chicago

Christopher Lau

U.S. EPA/ORD/NHEERL/TAD

Nancy LaVerda

The George Washington University

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Cindy Lawler
NIEHS

Pamela Lein

University of California, Davis
Victoria Leonard

University of California, San Francisco

Edward Levin

Duke University

De-Kun Li

Kaiser Permanente

Sylvana Li
U.S. EPA/NCER

Yuli Li

University of Pennsylvania

Chung-Ho Lin

University of Missouri

Jianghong Liu

University of Pennsylvania

Rachel Locke

Children's Environmental Health Network

Nica Louie
U.S. EPA/NCER

Jennifer Lowry

Children's Mercy Hospital

Michael Lu

HHS/HRSA

Sara Lundgren

Dartmouth College

Michelle Mabson

ORISE Fellow at U.S. EPA

Jaime Madrigano

RAND Corporation

Chikezie Maduka

University of Maryland

Maureen Malloy

ICF International

Jennifer Mann

Berkeley/Stanford CEHC

Linda McCauley

Emory University

Rob McConnell

University of Southern California

Meredith McCormack

Johns Hopkins University

Amy McCune

4-H National Headquarters/USDA
Leyla McCurdy

Health and Environment Consulting

Shawn McElmurry

Wayne State University

Cynthia Mcoliver
U.S. EPA/NCER

John Meeker

University of Michigan

Suril Mehta
U.S. EPA/OCHP

Jacquelyn Menghrajani
U.S. EPA/OCHP

Catherine Metayer

University of California, Berkeley

Gregory Miller
U.S. EPA/OCHP

Mark Miller

Western States PEHSU (at
UCSF)/CIRCLE/Cal EPA

Lindsey Mitchell

University of Michigan

Stormy Monks

Texas Tech University Health Science
Center El Paso

Meghan Moynihan

University of Michigan

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Susan Murphy

Duke University

Carolyn Murray

Dartmouth College

Nathan Mutic

Emory University

Kari Nadeau

Stanford University

Olga Naidenko

AAAS Science and Technology Policy Fellow

Chris Nidel

Nidel Law PLLC

Bridget O'Brien
U.S. EPA/OSWER

Barbara O'Brien

Westat

Liam O'Fallon

NIEHS

Rebecca Ofrane
U.S. EPA Region 2

Kim Osborn

ICF International

Thomas Palys

Dartmouth College

Mili Pate I

HHS/ASPR

Laura Paulin

Johns Hopkins University

Emma Pennea

Mid-Atlantic Center for Children's Health 6t
the Environment

Frederica Perera

Columbia University

Bradley Peterson

Children's Hospital Los Angeles/University
of Southern California

Karen Peterson

University of Michigan

Anna Pollack

George Mason Unviersity

Lesliam Quiros-Alcala

University of Maryland, College Park

Stephen Rappaport

University of California, Berkeley

Chris Rea

ORISE Fellow at U.S. EPA

Khesha Reed
U.S. EPA/OCHP

Linda Reese-Smith

Rebecca Rehr

Maryland Environmental Health Network
Joshua Robinson

University of California, San Francisco

John Rogers

U.S. EPA/ORD/NHEERL

Melissa Rose

University of California, Davis

Angana Roy

The Cadmus Group, Inc.

Leslie Rubin

Morehouse School of Medicine/Emory
University

Sheela Sathyanarayana

University of Washington/Seattle Children's
Research Institute

Susan Schantz

University of Illinois

Racquel Segall

BlueGreen Alliance

Perry Sheffield

Mount Sinai Hospital

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Chris Sibrizzi

ICF International

Brianna Sleezer

Children's Environmental Health Network
Meghan Smith

Maryland Department of Health 6t Mental
Hygiene

Agnes Soares da Silva

WHO/PAHO

Shaina Stacy

Brown University School of Public Health
Tenya Steele

Center for Environmental Health
Tracy Stewart

Rita Strakovsky

University of Illinois

William Suk

NIEHS

Patrice Sutton

University of California, San Francisco
Maureen Swanson

Learning Disabilities Association of America

Allison Sylvetsky

George Washington University

Siobhan Tarver
U.S. EPA

Laura Thomas

ICF International

Claudia Thompson

NIEHS

Caitlin Tompkins

Georgetown University

Kate Topalis

Mid-Atlantic Center for Children's Health 6t
the Environment

Leonardo Trasande

New York University

Kristie Trousdale

Children's Environmental Health Network
Maria Valenti

Collaborative on Health and Environment

Judy Van de Water

University of California, Davis

Lisa Vasquez

HHS/HRSA

Prentiss Ward
U.S. EPA Region 3

Deborah Watkins

University of Michigan

Paul Wax

American College of Medical Toxicology

Lois Wessel

Georgetown University

Todd Whitehead

University of California, Berkeley

Joseph Wiemels

University of California, San Francisco
Nsedu Witherspoon

Children's Environmental Health Network
Tracey Woodruff

University of California, San Francisco
Alan Woo If

Boston Children's Hospital

Katherine Worden

ICF International

Rosalind Wright

Mount Sinai Hospital

Bowen Yao

University of Pennsylvania

Mahsa Yazdy

Harvard University

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Zhenzhen Zhang

University of Michigan

Marya Zlatnik

University of California, San Francisco

Ami Zota

George Washington University
David Zucker

Healthy Babies Bright Futures

157


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