United States
Environmental Protection
kl *m Agency
U. S. Environmental Protection Agency
Science to Achieve Results
Environmental Public Health
Indicators (EPHI) Research
Impact Report
March 2018
Data and methods that support environmental
public health decision-making by communities
Air Pollution
Children's Health
Surface/Drinking Water
ijairairsi
Asthma
Environmental Policy
Heavy Metals
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DRAFT EPHI Impact Report - March 2018
Disclaimer
The research described in this document has been funded wholly by the U.S. Environmental Protection Agency (EPA)
under the Science To Achieve Results (STAR) grants program. The information provided does not necessarily reflect the
views of the Agency, and no official endorsement should be inferred. Mention of trade names or commercial products
does not constitute endorsement or recommendation by EPA for use. The information presented in this report is
intended to provide the reader with insights about the progress and scientific achievements of STAR research grants. The
report lists the grantees whose research is discussed and indicates where more detailed peer-reviewed scientific
information can be found. This report is not intended to be used directly for environmental assessments or decision
making. Readers with these interests should instead consult the peer-reviewed publications produced by the STAR grants
and conduct necessary data quality evaluations as required for their assessments. EPA has received permission to use the
images within this document.
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Contents
Contents 3
EPHI Research Highlights 5
Background 6
EPHI Grant Discoveries 9
Decision-Support Indicators 9
Measuring Respiratory Health Impacts of Particulate Matter Reductions 9
Using Proximity to Toxic Emissions as a Measure of Environmental Health and Economic Impacts 10
Longitudinal Indicators of Policy Impact on Pollution, Exposure, and Health Risk 12
Considering Spatial Relations between People, Emissions, and Exposures to Improve Decision-Making 12
Tribal Environmental Public Health Indicators 13
Air Quality-Related Indicators 17
Indicators Evaluating Potential Links Between Air Pollutant Exposure and Health Effects 17
Components of Fine Particulate Matter and Cardiovascular and Respiratory Disease Indicators 17
Fine Particulate Matter Exposure and Cardiovascular Disease Indicators 18
Course Particulate Matter and Cardiovascular and Respiratory Disease Indicators 18
Traffic-Related Air Pollution Exposure and Asthma Indicators 19
School Environment and Children's Health and School Performance Indicators 20
Chlorinated Solvents Exposure and Birth Defects Indicators 21
Indicators of Health Outcomes Related to Air Pollution 21
Asthma and other Respiratory Effects Indicators 21
Cardiovascular Effects Indicators 22
Immunological Effects Indicators 23
Indicators of Exposure to Air Pollutants 24
Mobility-based Air Pollution Exposure Indicators 24
Integrated Mobile Source Indicators (IMSI) 24
Traffic Exposure Indicators 25
Drinking and Surface Water 26
Arsenic Drinking Water Exposure and Heart Disease Indicators 26
Mercury Exposure Indicator that Considers Selenium 27
Indicators of Exposure to Perfluorooctanoic Acid 28
Waterborne Pathogen Indicators for Recreational Waters 29
Multipathway Pollutant Exposure Indicators 30
Arsenic Exposure Indicators 31
Organochlorine Exposure and Type 2 Diabetes Indicators 32
Other Stressor Exposure and Health Outcome Indicators 33
Pollen Exposure and Allergic Disease Indicators 34
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Heat-related Excess Mortality Indicators 35
For More Information 36
Appendix A. EPHI Grants 37
Appendix B. Publications Attributed to EPHI Grants 40
Cited References 46
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EPHI Research Highlights
The U.S. Environmental Protection Agency (EPA) initiated its Environmental
Public Health Indicators (EPHI) research program in 2006. Since then, EPA
competitively funded 20 extramural Science-to-Achieve Results (STAR)
grants. These grants researched and developed EPHI that help identify
predictive linkages between environmental hazards, human exposures, and
disease outcomes. To date, total funding for the program was $9.5M. All the
EPHI grants are now complete. This report summarizes findings,
accomplishments, and impacts of EPA's EPHI research program.
EPHI indicators have directly supported health interventions, informed policy
and decision-making, and improved the understanding of the links between environmental exposures and health effects.
The results have helped public health professionals identify susceptible individuals and communities in the greatest need
of interventions. They have assisted decision-makers in identifying opportunities for protective actions and in
understanding the economic impacts of environmental stressors in their communities.
Specific EPHI research program accomplishments and impact highlights—outcomes—include the following:
¦ Conducted human health studies linking particulate matter and cardiovascular health effects which were among the
evidence considered by EPA in its 2009 Integrated Science Assessment for Particulate Matter that informs the
National Ambient Air Quality Standards.
¦ Contributed to Minnesota's Clean Air Dialogue Work Group decision to reduce emissions in Minnesota.
¦ Identified association between peak tree pollen and allergy health effects that was cited in a New York City
Department of Health and Mental Hygiene health advisory regarding risk of asthma exacerbation due to pollen.
¦ Characterized over time community exposures to and sources of perfluorooctanoic acid in the Mid-Ohio River Valley
and the findings were among the evidence that led to improvement in municipal drinking water treatment methods.
¦ Tested novel indicators of exposure to waterborne pathogens and confirmed the predictive accuracy of a rapid water
quality indicator developed by EPA, which has been adopted by Chicago Park District to improve their beach
monitoring.
¦ Developed a significantly improved measure of mercury exposure from seafood that more accurately accounts for
selenium interactions, providing information helpful to guide pregnant and breastfeeding women's seafood choices.
¦ Identified and analyzed indicators of heat-related illness linked to heat-related death, which informed the National
Weather Service's revision of its heat advisory threshold for New York City.
¦ Completed ground breaking studies of effect of hazardous waste cleanups on infant health and analysis of
community economic impacts of toxics-emitting plants.
¦ Developed visual methods to identify the greatest potential improvements among air pollution emission sources
considering efficiency, equality, and justice.
¦ Developed, refined, applied, and shared Indigenous Health Indicators that better capture American Indian cultural
health values to inform tribal environmental decision-making.
¦ Discovered new information about the exposure-response relationship between particulate matter and asthma
emergency department visits and hospital admissions.
¦ Identified temporal trends in school children's asthma hospital admissions and associations between teacher health
and school characteristics, which demonstrate the importance of healthy school environments.
¦ Analyzed geographic data sets in combination with birth outcome data for the largest study population ever to
identify risk factors for birth defects,
¦ Confirmed feasibility of new indicators of asthma, other respiratory effects, and immunological effects.
¦ Capitalized on cell phone GPS technology in combination with GIS data to develop new measures of traffic exposure.
¦ Identified associations between heart disease and low-level arsenic exposure via drinking water.
¦ Identified dietary sources of arsenic as a primary exposure pathway.
¦ Developed biomarkers of exposure to phased-out pesticides in agricultural part of Mississippi.
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What is an indicator?
An indicator provides an easily interpretable
measure of the state of the environment or health of
a population.
Environmental public health indicators (EPHIs)
provide information about a population's health
status with respect to environmental factors. They
can be used to assess health or a factor associated
with health in a specified population through direct
or indirect measures.1 There are two types of EPHIs:
¦ Exposure indicators, which measure or estimate
the direct contact of humans with chemicals in
their environment. These can be tied to
projected health outcomes using toxicity
information or epidemiological data that relate
exposure to health outcomes.
¦ Outcome indicators, which measure actual
environmental or health-related results such as
cleaner air or water or reduced incidence of
disease known or believed to be caused by
exposure to environmental pollutants.
Since 2012, EPA pivoted toward the development
and application of sustainability indicators. This type
of indicator is defined as a measurable aspect of
environmental, economic, or social systems that is
useful for monitoring changes in system
characteristics relevant to the continuation of
human and environmental well-being.2 EPHIs are
sustainability indicators.
Background
Environmental Public Health Indicators
The Environmental Public Health Indicators (EPHI) research
supported through the U.S. Environmental Protection Agency's
(EPA) Science to Achieve Results (STAR) grant program has
supported the development of new and improved indicators of
linkages among environmental hazards, human exposures, and
public health disease outcomes. EPHIs can be used for assessing
the actual impacts of environmental risk management decisions,
long-term tracking and surveillance of environmental public
health, or informing health or environment-related decisions.
These indicators provide ways to measure and track the state of
the environment or better monitor community health at a local,
regional, or national scale.
EPA's mission is to protect human health and the environment.
Early Agency efforts focused on improving the ability to assess
exposure, toxicity, and risk. More recently, efforts have expanded
to include identifying predictive or consequential linkages
between pollutants and health outcomes where health outcomes
are changes in human health that result from exposure to
chemicals and/or other stressors present in the environment.
Health outcome indicators measure the occurrence in a
population of diseases or conditions that are known or believed to
be caused by exposure to environmental pollutants. Health
outcome indicators can be derived at a community, regional, or
national level based on the data used in their development.
Health outcome indicators can be used to:
¦ describe the health status of a population and discover
important temporal and spatial behaviors of diseases;
¦ identify causal factors for specific diseases or trends that
explain disease prevalence or exposure occurrence;
¦ predict disease occurrence from the distribution of exposure for a specific population; or
¦ evaluate the health impact of environmental policy decisions or interventions.
The Significance of EPHI Research
A growing number of emerging contaminants are suspected of contributing to adverse health outcomes, but many
exposure-outcome relationships remain uncertain. Although chronic diseases are leading causes of disease and death in
the U.S., the contribution of environmental factors to chronic health effects is not well understood. In addition,
environmental health managers and policy-makers often are asked whether changes in environmental policies produce
demonstrable improvements in public health outcomes. The research conducted by EPA's EPHI grantees can help answer
these important questions. Use of EPHIs and associated data can lead to better-informed public and science-based
environmental health policies and decisions.
EPHI research results provide communities and decision-makers:
¦ A better understanding of the associations between pollutants and their impact on environmental quality, human
exposure, and the cumulative effects on health and disease.
¦ An improved understanding of variability of pollution impact over time, geographic location, and population type and
size, and environmental health disparities.
¦ Public health surveillance, tracking, and early-warning information.
¦ Opportunities to understand or demonstrate actual impacts, progress, or effectiveness of environmental health
decisions or programs on human health or environmental goals.
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¦ Evidence to inform formulation of strategies and development of future environmental health management
programs or goals.
Information provided by EPHI research helps communities navigate efforts to achieve sustainability and measure
progress.
The EPHI grant program is part of a larger EPA environmental indicators effort that aims to improve the assessment of the
"state of the environment" that results from local, state, and federal risk management decisions intended to improve
environmental quality and human health. The challenge for this effort, and for other environmental and public health
indicator initiatives, is to link national-level indicators of pollutants to actual human exposures and health outcomes.
EPHI Grant Basics, Publication Outcomes, and Career Impacts
In total, EPA awarded $9.5 million through 20 EPHI grants to academic and nonprofit institutions. The locations of these
awards are shown geographically in Exhibit 1 and listed in Appendix A. EPA's STAR program awarded these research
grants through a competitive solicitation process, which included both an independent external peer review for scientific
merit and an internal review for relevance to EPA's research priorities. Ten grants, awarded from two solicitations in 2007
& 2008, focused on outcome-based environmental health indicators that could reliably signal trends in source to
exposure, exposure to outcome, and ultimately source to exposure to outcome relationships. These indicators will be
helpful in evaluating the public health impacts of changes in environmental conditions, management approaches, or
policies. Ten grants, awarded from a 2011 solicitation, focused on developing indicators for long-term tracking and
surveillance of environmental public health, making better informed decisions, and assessing the actual impacts of
environmental risk management decisions. Environmental public health tracking-the ongoing collection, integration,
analysis, and dissemination of data-can be done at the local, state, or national level.
Scientific publications resulting from these 20 STAR EPHI grants are presented in Appendix B. To date, there are 115
journal publications and 4 book chapters, with the most recent publication in January 2018. Using cost per publication as
a metric to evaluate the productivity of this set of 20 grants (which included analysis of large data sets, numerous
scientifically innovative approaches, and human subjects research), the cost per publication was less than $80,000. Of the
EPHI publications, 100 are indexed in the Web of Science Core Collection and:
• span 32 different research categories;
• include contributions from 208 different authors;
• have been cited over 2,600 times (not including self-citations) in over 2,100 articles with nearly 100 in the first
three months of 2018;
• represent collaborations with eight state or local government agencies, four tribal governments or organizations,
six different branches of the federal government and authors representing eight different countries;
• include two "Highly Cited Papers," meaning each received enough citations to place it among the top 1% in their
academic fields of Environment/Ecology (cited 230 times) and Social Sciences (cited 154 times); and
• include seven papers cited over 100 times and 32 papers cited over 20 times.
Twelve of the 20 EPHI principal investigators responded to a recent inquiry concerning the educational support provided
by these EPHI grants. More than 24 early career researchers were involved in the research efforts, including 10 PhD
students, seven Mater's students and three post-doctoral researchers.
Relevance of EPHI Research to EPA's Strategic Plan
In February 2018, EPA published the FY2018-2022 EPA Strategic Plan3. Although this research was initiated and
completed before publication of this strategic plan, the body of research contributed through these research grants to the
scientific community supports Goal 1 of the Strategic Plan "Core Mission: Deliver real results to provide Americans with
clean air, land, and water, and ensure chemical safety." This Strategic Goal indicates EPA will use the best available
science and research to address current and future environmental hazards, develop new approaches, and improve the
foundation for decision making. This goal highlights EPA's desire to collaborate with other federal agencies, states,
sovereign tribal nations, local governments, communities, and other partners and stakeholders to address existing
pollution and prevent future problems and pay particular attention to vulnerable populations. The suite of research
supported by the STAR grant EPHI program is composed of collaborative and innovative research efforts that illuminate
environmental threats to public health and vulnerable communities and support EPA's core mission.
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DRAFT EPHI Impact Report - March 2018
EPHI Grant Discoveries
Decision-Support Indicators
There is a desire to expand the amount and quality of evidence-based and data-driven information to inform
environmental decision-making. All EPHIs have the potential to support, directly or indirectly, decisions by communities
and governments at multiple levels. Highlighted here are five EPHI research efforts that delivered results particularly
beneficial to evaluations of policy or other actions, and informed planning and prioritization decisions. The first three
sections present studies conducted over time-spans when reductions, or increases followed by reductions, of pollutants
took place. The studies look at different measures of exposure, health outcomes, or economic impacts over the same
time periods to evaluate the accuracy of proposed indicators to demonstrate actual impacts, progress, or effectiveness of
policy decisions on human health or environmental goals. The fourth section presents a tool for policy makers to use in
evaluating sometimes conflicting considerations when considering reductions to environmental exposures. The final
section presents novel research on the development of indicators for tribal communities reflective of a broader definition
of health and wellbeing embraced by many tribal communities.
Measuring Respiratory Health Impacts of Particulate Matter Reductions
EPHI researchers at the Minnesota Department of Health, Minnesota Pollution
Control Agency, and Olmsted Medical Center, led by Dr. Jean Johnson, developed
and evaluated indicators to measure impacts of air pollution reductions on
exposures to fine particulate matter and respiratory health outcomes.
gThe study areas for these EPHI efforts were the Minneapolis-St. Paul
metropolitan area and Olmstead County, Minnesota.4 The health outcomes
studied included total respiratory, chronic lower respiratory disease, and asthma
hospitalizations gleaned from existing hospital data sets. The researchers used
health outcomes and local air pollution data for a 2-year baseline period (2003-
2005) and-following reductions in air pollution resulting from implementation of several national, state, and local
regulations-additional data collected through 2009. Mean Average concentrations of particulate matter smaller than 2.5
microns in size were lower in later periods compared to the baseline period. The researchers found hospitalizations for
air-pollution related issues to be a significant indicator of particulate matter levels in the Minneapolis-St. Paul
metropolitan area using data from 2003-2009, the longest time-frame evaluated. However, there was not consistency in
the results across the health outcomes and different time periods evaluated in the study. In the study using only data for
Olmstead County, with its lower population and one continuous PM2.5 monitor, they found more asthma occurrences in
areas with more car traffic and, coincidentally, with higher poverty rates.
What is Particulate Matter (PM)?
PM is used to refer to a mixture of solid
particles and liquid droplets found in the
air. It is made up of very fine dust, soot,
smoke, and droplets that are formed from
chemical reactions and produced when
fuels such as coal, wood, or oil are burned.
PM air pollutants are so small that they can
be inhaled and cause health problems by
getting deep in a person's lungs and enter
his or her bloodstreams. PM10 refers to
particles with diameters generally 10
micrometers and smaller. Finer particles,
known as PM2.5, are particles with
diameters generally 2.5 micrometers and
smaller. Exhibit 2 provides size comparisons
to visualize the different sizes of particulate
matter (PM) air pollution.5
Exhibit 2. Size comparisons for particles of particulate matter (PM)
air pollution.5
C PM2.5
Combustion particles, organic
compounds, metals, etc.
<2.5 |im f/TwercmsJ in diameter
HUMAN HAIR
c PM10
Dust, pollen, mold. elc.
<10 Hffl |7?i!CVDnsf in diameter
90 (im (rnicfans) n (Sarreter
FINE BEACH SAND
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| Dr. Johnson presented results from this EPHI grant to state legislators several times during testimony on the
health impacts of air pollution. The results also provided critical support to Minnesota's Clean Air Dialogue, a facilitated
stakeholder process in which leaders from the business, government and nonprofit sectors identify potential emission
reduction strategies that are efficient, effective and beneficial for Minnesotans and Minnesota industries. In April 2013,
Minnesota's Clean Air Dialogue Work Group members announced their recommendations to reduce emissions and keep
Minnesota's air clean, describing these EPHI grant findings in their final report. According to Dr. Johnson, the trends show
measurable positive impacts of PM reduction policies in the Twin Cities and will be used to further support clean air
initiatives.
"This EPHI STAR research has provided a critical foundation of evidence, using indicators for
tracking the success of air pollution reduction strategies and for protecting public health.
Building on the work over several years and working with community and business
partners, the investigators continue to support new initiatives reducing particulate matter
emissions and keeping Minnesota's air clean."
-Jean Johnson, PhD, Minnesota Department of Health
In another study, EPHI researchers at Johns Hopkins University and Harvard University, led by Dr. Francesca Dominici,
developed new methods to evaluate the effectiveness of air quality regulations in reducing levels of air pollution by
estimating the public health benefits of air pollution regulations, referred to as "accountability" research. They conducted
novel epidemiological studies linking data from independent data sets.
Results
The EPHI research team assessed whether the risk of exposure to particulate matter (PMio) changed when
several air quality regulatory programs were implemented.6 They identified weak evidence of a trend of decline in the
short-term effect of PMio on mortality from 1987 through 2000. Geographic differences in the trend also were noted. In
addition, they found larger effects for fine particulate matter. Day-to-day variations in all-cause and cardiopulmonary
mortality were associated with concentrations of fine particulate matter (PM2.5).
Impact
Although the study does not provide direct evidence of health benefits, its approach offers a quantitative way
to assess whether the association between day-to-day changes in pollution levels and health effects weakens over time.
This research is an important component of responsible governmental policy intervention and environmental health
tracking research.
Using Proximity to Toxic Emissions as a Measure of Environmental Health and Economic Impacts
Communities have many questions while considering actions to protect
health or improve their economies. One way to address these uncertainties
is to compile and analyze new sets of "big data," which unite and enable
analysis of diverse measures of health, location, exposure, and economics.
An EPHI grant to Princeton University, led by Dr. Janet Currie, investigated
how a large and comprehensive data set—geocoded Vital Statistics Natality
data collected from birth certificates—could be used to improve
understanding of the impact of environmental hazards. The records cover
millions of births over long periods and feature information about mothers'
birth outcomes, background, and residence location (coded for security).
These sets can be linked with other informative data sets for far-reaching analyses.
EPHI researchers used the database of Vital Statistics Natality records for five large states—Florida, Michigan,
New Jersey, Pennsylvania, and Texas and for New York City from 1989 to 2011. They geocoded residential location and
linked births to the same mother over time to calculate distances between maternal homes and environmental hazards,
They also incorporated economic data and performed economic impact analyses.
In one study, EPHI investigators sought to improve understanding of the environmental health impacts from EPA's
Superfund program cleanups.7 Starting in 1980, the Superfund program has helped protect human health and the
environment by managing the cleanup of the nation's worst hazardous waste sites.8 The researchers compared birth
outcomes before and after a site cleanup for mothers who live near and farther from some of the more hazardous
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DRAFT EPHI Impact Report - March 2018
Superfund sites. They found a 20 to 25% increase in anomalies at birth for infants born to mothers living within one mile
of the Superfund sites compared to infants born to mothers living further away from the sites. In other words, the results
suggest that Superfund cleanups reduced the incidence of anomalies detected at birth by approximately 20-25%.
In another study, Dr. Currie's team focused on environmental health outcomes and housing value impacts associated with
proximity to industrial plants that emit toxic pollutants as reported to EPA's Toxic Release Inventory.9 They linked
information on the location and activities of the 1,600 plants with information on nearby birth outcomes and housing
transactions. They found that housing prices within 0.5 miles of a toxics-emitting plant decreased by about 11% after the
plant opened, relative to the price before the plant was built (see Exhibit 3). For an average plant opening, this decline
indicates an aggregate loss in housing values of approximately $4.25 million. They also found that the incidence of low
birthweight increased by roughly 3% within 1 mile of operating toxics-emitting plants (see Exhibit 4). They identified
comparable magnitudes between 0 and 0.5 miles and 0,5 and 1 miles. In both analyses, no impacts on housing prices or
infant birthweight were found beyond 1 mile.
Exhibit 3. Event study plots of the effect of toxics-emitting plant openings and closings on local housing values. The plotted
coefficients show the time path of housing values 0-1 miles from a plant, relative to 1-2 miles from a plant, conditional on plant-
by-distance and plant-by-year fixed effects. The dashed lines represent 95% confidence intervals. The findings suggest that plant
openings (Panel A) led to housing price declines in the year of the plant opening. The results for plant closings (Panel B) are less
striking, but on average prices rose slightly after the year of a closing.8
Panel A. Housing value: Plant opening* Panel B. Housing value: Plant closing Q
Years before/after opening Years before/after closing
Exhibit 4. Effect of toxics-emitting plant openings and closings on the incidence of low birthweight. Shown are coefficients for
event-time that plot the time path of low birthweight "near" (i.e., less than 1 mile) relative to "far" (1 to 2 miles) before and after a
plant opening or closing. The dashed lines represent 95% confidence intervals.8
Panel A. Low birthweight: Plant opening Panel B. Low birthweight: Plant closing ^
Years bef o re /after opening Years before/after closing
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Impact
This research demonstrated the feasibility of using existing data in novel ways to assess environmental hazards.
The approach was made possible through access to confidential Vital Statistics Natality data and the large samples
provide statistical power to detect health effects from relatively low levels of pollution. The information is responsive to
critical environmental and economic questions posed by communities and decision-makers.
The grant generated ground-breaking studies. One was the first to examine the effect of hazardous waste cleanups on
infant health rather than focusing on proximity to a site.6 Another was the first large-scale empirical analysis of the
external costs of toxics-emitting plants.8 The research on health outcomes led Dr. Currie and her fellow researchers to
conclude there is strong evidence that early-life exposure to pollution can have long-term consequences later in life and
the benefits of pollution control may be particularly high for children—a more vulnerable segment of the population.10
Longitudinal Indicators of Policy Impact on Pollution, Exposure, and Health Risk
Developing improved measures of the effectiveness of environmental policies is increasingly important for decision-
making. An EPHI project at Johns Hopkins University, led by Dr. Thomas Burke, collaborated with the New Jersey
Departments of Environment and Health to address this need. The project applied risk assessment as an indicator to
represent potential impacts on public health and used it to evaluate the impact of environmental policies on population
exposures and health risks for New Jersey.
Results
The EPHI investigators applied risk assessment methods to translate environmental monitoring and surveillance
data into metrics of health risk. They then used risk assessment to evaluate health risks from polychlorinated biphenyls
(PCBs) in fish and trichloroethylene (TCE) in drinking water prior to and after implementation of environmental policies to
regulate the contaminants.11 Their analyses showed a quantifiable drop in cancer risk from PCB levels pre-ban to post-
ban; however, due to the environmental persistence of PCBs, the non-cancer risks remained elevated for some scenarios
ten years' post-ban. For TCE, their analyses showed progress toward reduced TCE in drinking water. Their analyses
indicate reductions in environmental pollutants, exposures, and population risks because of implementation of state and
national environmental policies.
Impact
This EPHI grant work contributed to the growing body of knowledge on longitudinal indicators of environmental
progress. The longitudinal approach they used to track pollutants and exposures provides a valuable tool for evaluating
and improving the effectiveness of environmental policies. Although direct impacts of the research are difficult to
measure, the EPHI investigators continue to apply the methods to other community and national environmental issues.
"This research developed approaches to combine historical pollutant measures with risk
analysis to assess the impact of environmental policies. The work highlights the critical role
of state-level environmental monitoring programs in tracking environmental progress and
evaluating the effectiveness of national policies."
-Thomas Burke, PhD, Johns Hopkins University
Considering Spatial Relations between People, Emissions, and Exposures to Improve Decision-Making
Decision makers need methods to evaluate and prioritize
activities to improve air quality. California's South Coast Air
Basin surrounds the city of Los Angeles. This area provides an
important case study because of its large population (16
million), generally poor air quality, and extensive ambient air
monitoring network. EPHI investigators at the University of
Minnesota, led by Dr. Julian Marshall, used data from Southern
California to model how reductions in diesel-generated fine
particulate matter from specific sources could change various
measures of environmental equality and justice.
Results
The EPHI researchers quantified how reductions in
emission of fine diesel particles from specific sources—on- and
off-road vehicles, ships, trains, and stationary sources-would change various measures of environmental equality and
justice. The four environmental measures they assessed were: impact, efficiency, equality, and justice as defined in
Exhibit 5.12 On- and off-road source categories were the largest sources of fine diesel particulate matter. Hispanic and
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non-white householders with incomes in the bottom 25th percentile showed a 44% higher mean population average
intake compared to their white non-Hispanic households with incomes in the top 25th percentile. This disparity in average
intakes for the two different categories of households was true for every source category of fine diesel particles.
Exhibit 5.
Air pollution metrics considered in Southern California diesel-generated fine particulate matter scenario.12
Metric
Description
Impact
Total intake, total amount inhaled by the population per day
Efficiency
Intake fraction: the fraction of emissions from a given source category inhaled by the population
Equality
Atkinson index, a metric that quantifies income inequality used to reflect the goal of having equal
exposure among all people; 0 represents perfect equality; 1 represents maximum inequality
Justice
Relative percent difference between average exposure for high-income whites with income in the upper
25% percentile vs. low-income nonwhites with income in the lowest 25% percentile
H This EPHI research offers decision-makers a way to consider multiple metrics when comparing different
emission reduction options. The method can be expanded to evaluate more specific options that target specific sources,
such as ships or trains. They are also useful in showing the effect of changes in location-specific emissions, such as for
trains or ships. The findings revealed the significance of train and on-road emissions for fine diesel particulate matter
pollution in the southern coastal region of California. The researchers estimated reductions in train emissions would
produce the greatest improvements in terms of efficiency, equality, and justice. They found that reductions in on-road
emissions would produce improvements in impact, equality, and justice. Emission reductions from ships, however, could
exacerbate existing population inequalities. On- and off-road mobile sources together contributed most of the total
emissions. This multi-scenario approach helps communities quantify and prioritize actions to address air pollution
challenges.
Tribal Environmental Public Health Indicators
Indigenous communities, including American Indian and
Native Alaskan communities have concerns about the
health of their people like many other communities.
Tribes have been requesting the use of tribal-specific
definitions of health in health risk assessments, but
approaches were lacking. One challenge is that
conventional health assessments focus on a narrow
concept of health that concentrates on disease and
physiological measures. Tribal communities tend to have
broader definitions of health and wellbeing. No measures
were established that reflect the multilevel (e.g., familial,
tribal) and complex connections between people, nature,
and the spirit world that many Indigenous people in the
U.S. consider essential to health and wellbeing. An EPHI
grant to the Swinomish Tribal Community, led by Dr. Jamie Donatuto, built on previous work to create and test EPHII
specific to Native American tribal communities in the Puget Sound/Salish Sea region of the Pacific Northwest. See Exhibit
6 for information about the Swinomish Tribe.
gThe Swinomish partnered with the Lower Elwha Klallam Tribe, the Port Gamble S'Klallam Tribe, the Suquamish
Tribe, and the Stillaguamish Tribe on this EPHI grant project that expanded a preliminary set of indicators developed
under a previous STAR project (Bioaccumulative Toxics in Native American Shellfish, R829467).13 The EPHI researchers
used a community-based approach with multiple research methods—individual interviews, group workshops, ranking
with descriptive scales, weighting techniques—to identify more specific and contextual Indigenous health risks and
impacts.14 They developed and tested a set of six Indigenous Health Indicators, each with specific attributes and measures
(see Exhibits 7 and 8).
In subsequent work, the investigators tested the efficacy of the indicators in two Indigenous communities to identify
coastal climate adaptation priorities for Coast Salish communities. The results informed gaps in the Swinomish Climate
Change Adaption Action Plan (2010), which supports coastal zone planning and decision-making on the Reservation.15
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DRAFT EPHI Impact Report - March 2018
Exhibit 6. Swinomish is a U.S. federally recognized American Indian
Tribe. The Tribe occupies the Swinomish Indian Reservation on the
southern portion of Fidalgo Island in Washington State. The
Swinomish are fishing, hunting, and gathering people and 90% of
the reservation is bordered by water.13
Clockwise from left • Coast Salish canoe families patiently waiting
to request to come ashore at the Paddle to Swinomish of 2011.
Photo by Caroline Edwards. • First Salmon Ceremony and Blessing
of the Fleet. The Swinomish Canoe Family sings a blessing song for
the salmon and for the safety of fisherman. Photo by Caroline
Edwards. • The Salmon Dancer Canoe Family paddles along the
shorelines of Swinomish, Photo by Ann Smock.
Exhibit 7. Six Indigenous Health Indicators reflect health considerations essential to the Swinomish Tribe way of life.14
Community Connection
Work—Community members have a job or role they and other community members respect, and they work together (mutual appr eciation,
respect, cooperation).
Sharing—Community members engage in active sharing networks, which are integral to a healthy community, ensuring that everyone in the
community receives traditional foods and other natural resources such as plant medicines, especially Elders.
Relations—Community members support, trust, and depend on each other.
Natural Resources Security
Quality—The natural resources, including the elements (e.g., water), are abundant and healthy.
Access—All resource use areas (i.e., Usual and Accustomed areas in WA) are open to harvest/use (not closed or privatized) by community
members.
Safety—The natural resources themselves are healthy, not affected by pollution, climate change, etc.
Cultural Use
Respect/Stewardship—Community members are conferring respect of/to the natural resources and connections between humans,
environment and spirit world; ensuring cultural resources are properly maintained.
Sense of Place—Community members are engaging in traditional resource-based activities, which is a continued reminder/connection to
ancestors and homeland.
Practice—Community assemblies able to follow appropriate customs (e.g., can obtain specific natural resources if needed such as cedar,
certain foods) and to honor proper rituals, prayers, and thoughtful intentions. Community members feel they are able to satisfy
spiritual/cultural needs, for example, consume foods and medicines to satisfy Spirit's "hunger."
Education
The Teachings—The community maintains the knowledge, values, and beliefs important to them.
Elders—The knowledge keepers are valued and respected and able to pass on the knowledge.
Youth—The community's future is able to receive, respect, and practice the Teachings.
Self-Determination
Healing/restoration—The availability of and access to healing opportunities (e.g., traditional medicines, language programs) for community
members, and the community's freedom to define and enact their own, chosen environmental, health, and habitat restoration programs.
Development—The ability for a community to determine and enact their own, chosen community enrichment activities in their homelands
without detriment from externally imposed loss of resources.
Trust—The community trusts and supports its government.
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DRAFT EPHI Impact Report - March 2018
Resilience
Self-Esteem—The beliefs arid evaluations community members hold about themselves are positive, providing an internal guiding mechanism
to steer and nurture people through challenges, and improving control over outcomes.
Identity—Community members are able to strongly connect with who they are as a community (Tribe or Nation) in positive ways.
Sustainability—The community is to adapt (e.g., people hunt with guns and use motorboats today but that does not discount the significance
of harvesting) and move within homelands voluntarily in response to changes (the "7 generations thinking").
Exhibit 8. Six Indigenous Health Indicators reflect health considerations essential to the Swinomish Tribe way of life.1615
(Graphic developed by Emma Fox, Swinomish Communications Department)
The Indigenous Health Indicators (IHI) are a set of community-scale, non*physical aspects
of health that are integral to Coast Salish health and wellbeing. The IHI reflect deep
connections between humans, the local environment and spirituality. IHI provide a
template for resource'based communities to tailor in order to suit their own, unique
connections and health priorities.
Un> | f>K» W-7W1 | k»mpbtSe*wt*wi*hHMi y» JiMt DwiMuto f (MO) W-1S3I ) n*n •»
Swwemiih Endiui CO(na«nity | 17jj; U fonMr. WA, WHJ | fay/WiV
talxcut
SELF DETERMINATION
Healing & Restoration *
Development • Trust
yayusbid
CULTURAL USE
topwi & Stewardship • Sense
of Place • Practice
Pashigfad ta ad?iisad
COMMUNITY CONNECTION
Work • Sharing • Relations
INDIGENOUS HEALTH INDICATORS
s?utixdx* ti swatix'tad
NATURAL RESOURCES SECURITY
Quality • Accesi » Safety
icacusadad *
EDUCATION
The Teachings •
Elders* Youth
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RESILIENCE
Self-Esteem • Identity
t * Sustainability a
^^23 The Indigenous Health Indicators have been shown to be a technically effective tool for recognizing and equitably
incorporating Indigenous considerations and prioritizations of health into environmental public health assessments. They
have been used in numerous ways in multiple communities because the measures for each indicator can be tailored to fit
an individual community's health beliefs and priorities. The article describing these indicators has been viewed more than
1200 times according to the journal (the same IP address is counted only once) by viewers on every continent of the
world but Antarctica ,14 In addition, this work stimulated additional research collaborations between the Swinomish Tribe
and the National Libraries of Medicine, the National Science Foundation, and the North Pacific Landscape Conservation
Cooperative, among other government organizations.
An additional STAR grant was also competitively awarded to the Swinomish to use the Indigenous Health Indicators as the
primary assessment tool to determine community health impacts from changes in habitats of culturally important foods
such as salmon due to sea level rise and increased storm surge. This information is being incorporated into the Swinomish
Climate Change Action Plan. The information is also used for year 1 and 5-year planning and decision-making about the
Tribe's shorelines and first foods. The indicators are also integral to the first Swinomish Community Public Health
Assessment.
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DRAFT EPHI Impact Report - March 2018
The Indigenous Health Indicators are the basis for the 13 Moons environmental health curriculum, one of the first
environmental health curricula developed in Indian Country. A website provides information (see Exhibit 9). The
curriculum will be formally published in 2018 and is already taught in the local public school, at Northwest Indian College
and within the community.
Swinomish staff worked with other tribal communities to tailor the Indigenous Health Indicators for their community
health priorities and needs. For example, the Tsleil-Waututh First Nation (British Columbia, Canada) amended the
Indigenous Health Indicators for use in an oil spill impact assessment project. The Squaxin Island Tribe (Washington State)
used them to assess community health impacts from ocean acidification. The Lumbee Tribe (North Carolina) used the
Indigenous Health Indicator process to develop their own Public Health Department. Within the broader scientific
community, this work supported the development of a framework of human wellbeing for ecosystem-based
management.17
Additional potential uses of the Indigenous Health Indicators include improvement of:
¦ human health risk assessments,
¦ health impact assessments,
¦ natural resource damage assessments,
¦ measuring baseline community environmental health and setting goals,
¦ ecosystem services evaluations, and
¦ social-ecological systems research.
S
'IHwwwgfvl
kjri
V !¦-.
ust THftJittNRfHSgw I05fI'CpiAlis AJJOUT
EACH INDIGENOUS HEALTH INDICATOR
- «|
COMMUNIIY CONNECTION NATURAL RESOURCES SECURITY
CULTURAL USE EDUCATION SELF DETERMINATION RESILIENCE
Exhibit 9. EPHI researchers established a website (http://www.swinomish-nsn.gov/ihi/) and held numerous discussions about the
need for and significance of establishing a set of environmental public health indicators specific to Indigenous communities.
"The Indigenous Health Indicators provide an innovative tool for indigenous communities
to more equitably evaluate community health based on their own health definitions, needs,
and priorities such that planning and decision-making by those communities and others is
based on more accurate data."
-Jamie Donatuto, PhD, Swinomish Tribal Community
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DRAFT EPHI Impact Report - March 2018
Air Quality-Related Indicators
Our nation's air quality has improved since the 1990s, but public health challenges remain. Air pollution exposures are
associated with increased emergency department visits and hospital stays for breathing and heart problems, asthma, and
increases in illnesses such as pneumonia and bronchitis.18 Air pollution can affect everyone, including citizens in both
urban and rural communities.
Presented here are 12 significant contributions to improving air pollution indicators from EPHI grants. These EPHI
researchers investigated the links between air pollution exposure and adverse (and costly) health outcomes, such as
cardiovascular events and hospitalizations.
EPHI research also reduced uncertainties for specific aspects of the air pollution source-to-receptor pathway. At the
source end, the researchers characterized sources that emit pollutants and measured air pollution levels, which helped
communities understand where pollution originates and how often people are exposed to unhealthy levels of air
pollution. At the receptor or people end, they identified cellular-level indicators of exposure to and effects from air
pollutants, also known as biomarkers. This research improved understanding of the mechanisms of how air pollutant
exposure contributes to disease.
Indicators Evaluating Potential Links Between Air Pollutant Exposure and Health Effects
Components of Fine Particulate Matter and Cardiovascular and Respiratory Disease Indicators
Researchers at Johns Hopkins University and Harvard University, led by
Dr. Francesca Dominici, identified compelling links between components
of fine particulate matter, PM2.5, and indicators of cardiovascular or
respiratory disease.
g EPHI researchers examined a large human population and
used real-world concentrations of particulate matter components. For
119 U.S. urban communities and 12 million Medicare enrollees (i.e., 65
and over), the researchers estimated associations between daily
concentrations of PM2.5 components and the risk of hospital
admissions.19 They evaluated major PM2.5 chemical components: sulfate,
nitrate, silicon, elemental carbon, organic carbon matter, and sodium
and ammonium ions, as well as weather. Among these constituents of
PM2.5, they found ambient levels of elemental carbon and organic carbon
matter to be associated with the largest risks of emergency
hospitalizations. Elemental carbon and organic carbon matter are
primarily generated from vehicles, diesel engines, and burning wood.
Multipollutant models also showed evidence that the risk of
cardiovascular admission associated with a same-day elemental carbon
concentration was larger than risks associated with any other PM2.5
component.
This grant also investigated the regional and seasonal variations of
short-term effects of fine particulate matter on cardiovascular and
respiratory hospitalizations among older adults in 202 U.S. counties.20
They found higher respiratory disease admissions in the winter while
cardiovascular admissions varied little by season. Regionally, the U.S.
Northeast showed the strongest evidence of an interaction between
PM2.5 and hospitalizations for both respiratory and cardiovascular
diseases. Fine particulate matter components with higher
concentrations in the seasons and regions that showed the largest
short-term effects of PM2.5 on hospitalization are associated with
several sources. These components corresponded to several
combustion sources and to metals and sea salt.
Findings (Johns Hopkins University and
Harvard University)
Identified two PM2.5 components-
elemental carbon and organic carbon
matter—as being associated with highest
risks of emergency hospitalizations.
Found evidence for association of organic
carbon matter with respiratory-related
hospital admissions.
Demonstrated regional and temporal
patterns in the association between PM2.5
and cardiovascular and respiratory
hospitalizations.
Impact
J] The research provided a significantly more complete picture of the health effects of particulate matter
chemical components. EPA cited results of this EPHI grant in its 2009 Integrated Science Assessment for Particulate
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DRAFT EPHI Impact Report - March 2018
Matter.21 This document is EPA's evaluation of the scientific literature on the potential human health and welfare effects
associated with ambient exposures to particulate matter. Development of this document is part of the Agency's periodic
review of the national ambient air quality standards (NAAQS) for particulate matter. EPA indicated that these grant results
suggest that the observed associations between PM2.5 and cardiovascular disease hospitalizations might be due primarily
to particles from oil combustion and traffic. As of March 2018, the two journal articles describing these grant results are
Highly Cited Papers, meaning each of them received enough citations to place them in the top 1% of their academic fields,
with Web of Science indicating the paper by Peng et. al,, was cited 229 times in papers representing 25 countries and the
paper by Bell et. al. was cited 154 times in articles representing 20 countries.19,20 The results also helped focus future
research and better design studies for evaluating the mechanisms of injury from particulate matter components. The
statistical tools the researchers developed provided a reproducible methodology applicable in future characterizations of
the health effects of complex mixtures.
Fine Particulate Matter Exposure and Cardiovascular Disease Indicators
An EPHI grant to the New York University School of Medicine and New
York City Department of Health and Mental Hygiene, led by Dr.
Kazuhiko Ito, evaluated using readily available health data for tracking
impacts of fine particulate matter on the cardiovascular health of
people in New York City.22
g By examining chief complaint data from emergency
departments, the researchers identified an association between
ambient fine particles and cardiovascular morbidity.23 In New York City,
chief complaint data is available to the Department of Health and
Mental Hygiene typically within 24 hours, making possible recognition
of sudden changes in cardiovascular illness related to ambient air
pollution and other environmental events.
Found that syndromic surveillance data—data
that are available as soon as 1 day after
occurrence, e.g., asthma and cardiovascular
emergency department visits:
¦ Are highly correlated with physician-
diagnosed emergency department visits
and hospitalizations data information that
suffers from long (e.g., 2-year) lag times;
¦ Are correlated with air pollution and
weather variables;
¦ Are effective tools to measure health
impacts of air pollution;
¦ Help detect unusual events; and
¦ Provide near real-time means to predict
and reduce health risks in response to
developing air pollution and
meteorological exposures.
In a related analysis, the researchers examined seasonal variations in
associations between PM2.5 constituent pollutants and cardiovascular
hospitalizations and mortality. Particulate components related to coal
combustion were associated with cardiovascular hospitalizations in the
winter and cardiovascular mortality in the summer, while local
combustion sources, such as traffic and residual oil burning, were
associated with cardiovascular outcomes throughout the year.24
jJThe research supported the ability to model, in near real-
time, acute cardiovascular outcome indicators of environmental
exposures in a large metropolitan area. The New York City Department
of Health and Mental Hygiene used the results of this study in their
health impact assessment for cleaner heating fuels and reduced motor
vehicle emissions.25,26 This work was influential in informing and
accelerating implementation of New York City's heating fuel
regulations to phase out the use of all heavy heating oil by 2030. The
Ito et al. study was cited 104 times according to Web of Science (March
2018) with citations representing research in 18 countries. This
research was also cited in the EPA's proposed rule presenting the
review of the Primary National Ambient Air Quality Standards for Oxides of Nitrogen in July 2017.27
Findings (New York University School of
Medicine and New York City Department of
Health and Mental Hygiene)
Course Particulate Matter and Cardiovascular and Respiratory Disease Indicators
EPHI researchers examined associations between particulate matter
levels and daily counts of cardiac or respiratory emergency hospital admission
Johns Hopkins University and Harvard University EPHI grant researchers filled
gaps in evidence regarding the health risks of exposures to coarse particulate
matter, that is, particles with diameters greater than 2.5 |im and up to 10 urn.
Primary emission sources of course particulate matter include mechanical
grinding, road dirt, windblown dust, and agricultural activities.
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DRAFT EPHI Impact Report - March 2018
data for 108 U.S. counties.28 The western U.S. showed levels of course particulate matter twice the levels detected in the
eastern U.S.. The eastern U.S., however, had higher levels of fine particulate matter (approximately 3 }-ig/m3) compared to
western states. After adjusting for exposures to fine particulate matter, the researchers found no statistically significant
associations between coarse particulates and hospital admissions for cardiovascular and respiratory diseases.
H The research helped fill a significant knowledge gap regarding the health impacts of course particulate matter.
This EPHI study was one of only three studies of course particulate matter EPA cited in its 2009 Integrated Science
Assessment for Particulate Matter.29 EPA also noted that this EPHI study was one of three "large, comprehensive, and
informative studies based on Medicare hospitalization data." In addition, other researchers have cited this EPHI study
article 177 times, with citations representing research in 24 countries, according to Web of Science (March 2018).28
Traffic-Related Air Pollution Exposure and Asthma Indicators
In one of the EPHI grants that looked specifically at children's health, a
grant to the Michigan Department of Community Health (now known as
the Michigan Department of Health and Human Services), University of
Michigan — Ann Arbor, and Michigan State University, led by Dr. Robert
Wahl, focused on acute childhood asthma events and daily air pollutant
levels. Whereas previous research focused primarily on linear
relationships between levels of air pollutants and asthma response, this
grant evaluated whether asthma emergency department visits and
hospital admissions indicated threshold exposure exist for different air
pollutants. The grant also evaluated whether there was a relationship
between asthma and traffic-related pollution.
Asthma is a chronic, multifactorial disease
characterized by:
Results
The analysis considered asthma emergency department visits
and hospital admissions for Detroit, Michigan children (2 to 18 years of
age) enrolled in Medicaid. They looked at a variety of air pollutants and
found concentrations of sulfur dioxide and PMis were associated with
asthma emergency department visits and hospitalizations, and evidence
indicated that proximity to major roadways was associated with asthma
events.30,31 The long-term trend of daily asthma events demonstrated a
seasonal pattern (Exhibit 10). The highest frequency occurred during
the fall, and the lowest during the summer. The findings demonstrated
the existence of a threshold effect in the range from 11 to 13 mg/m3for
PM2.5. The researchers also performed spatial analyses of asthma cases to evaluate associations with traffic exposures and
found moderately strong evidence of elevated risk of asthma close to major roads.
¦ Airway obstruction,
¦ Airway hyperresponsiveness,
¦ Airway inflammation, and
¦ Airway remodeling.
There has been a dramatic increase in the
prevalence of asthma worldwide in
industrialized countries.
Exhibit 10, Trend of daily counts of asthma events for pediatric Medicaid population (children 2-18 years of age) in Detroit,
Michigan, 2004 to 2006. Daily observations are shown as points with a trend shown as an overlaying fitted curve. The events include
emergency department visits without hospitalization, direct admission for hospitalization, and hospitalizations admitted through the
emergency department.30
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DRAFT EPHI Impact Report - March 2018
This research was important because risk assessments that assume linearity between air pollution levels and an
asthma response might underestimate the true risk. A threshold or nonlinear concentration-response relationship has
significant impact on risk assessment and risk management decisions. A response threshold would also have implications
for asthma education and management, and air pollution monitoring and warning systems.
School Environment and Children's Health and School Performance Indicators
In another EPHI grant that focused on impacts to children, an EPHI grant to the New York State Department of Health, led
by Dr. Shao Lin, developed new and improved on existing indicators related to the school environment. Many school-aged
children, teachers, and administrative and custodial staff spend substantial time in school buildings. Like other structures,
school buildings can be plagued by mold, vermin, allergens, vehicle exhaust intrusion, and problems with heating,
ventilation, or air conditioning. According to a 2012-2013 Department of Education survey, 25% of public schools rated
the indoor air quality of permanent and portable buildings as unsatisfactory or poor.32 They evaluated links between the
school environment and children's health and performance as well as the impacts of environmental policy intervention.
Results
Highlighted here are some of the results of the EPHI researchers' diverse research on indicators related to the
school environment.
¦ The proportion of U.S. children reported currently to have asthma increased from 8.7% in 2001 to 9.4% in 2010, but
then decreased to 8.4% in 2015.33 The researchers assessed whether asthmatic children were more likely to be
sensitized, exposed, or both to indoor allergens including pet dander, cockroach, dust mite, and mouse allergens,
compared to non-asthmatic children.34 The study observed significantly positive associations between children's
asthma and sensitization to dust mite, cat, and dog allergens. Children sensitized to cockroach allergens were more
likely to live in homes with higher levels of cockroach allergen. Compared to children without asthma, asthmatic
children were more likely to be sensitized and had significantly higher indoor exposure to cat allergens compared to
those who were only sensitized or only exposed to cat allergens. They also identified trends in asthma hospital
admissions among age groups and noticed school-aged children show some patterns around returning to school after
breaks.
¦ A school's indoor air quality is an important factor for the health of its
occupants. The EPHI researchers examined indoor air quality management
strategies between public elementary schools and their school districts in
New York State.35 They found that nearly half (47%) of the school district
respondents said they had a district-wide indoor air quality program.
Regarding specific strategies, the respondents most frequently reported
ventilating newly painted areas (92%). The least commonly reported
strategy was having a classroom animal policy (29%). Many school districts
lacked some important indoor air quality management strategies.
¦ The importance of teacher health cannot be overlooked. Teachers are a critical point of delivery for education and
their wellbeing contributes to their day-to-day success. EPHI researchers surveyed New York State school teachers to
assess building-related health symptoms and classroom characteristics.36 Approximately 500 teachers responded to
the survey. Their most commonly reported symptoms included sinus problems (16.8%), headache (15.0%),
allergies/congestion (14,8%), and throat irritation (14,6%). Experiencing one or more of these symptoms was
associated most strongly with reports of dust, dust reservoirs, paint odors, mold, and moldy odors.
Impact
The school environmental health indicators developed through this EPHI grant can be used for public health
surveillance tools and to develop interventions to improve health of students, teachers, and staff. For example, the
health symptoms reported among New York teachers while at work appear to be associated with characteristics related
to poor classroom indoor air quality. Efforts to improve school indoor air quality might improve teacher performance
and reduce sickness and absenteeism. The researchers informed key stakeholders of their results, including the New
York State Department of Health Environmental Public Health Tracking and State Education Department. The EPHI grant
experience helped the researchers achieve two new federal grant awards related to school environmental health.
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"The school environmental health indicators we developed in this study could be used by
other scientists and policy makers for research and diseases surveillance."
- Dr. Shao Lin, New York State Department of Health
Chlorinated Solvents Exposure and Birth Defects Indicators
In the U.S., approximately 1 in 33 infants is born with a defect.
Birth defects are among the leading causes of infant mortality. The
risk factors associated with approximately two-thirds of birth
defects are still unknown and could include environmental
exposures. For some types of birth defects, maternal exposure to
air pollution has been hypothesized as a factor. EPHI researchers
at Texas State University, Texas A & M Health Science Center,
Texas Department of State Health Services, and University of
North Carolina at Charlotte, led by Dr. F Benjamin Zhan, tackled a
difficult challenge in this area—to develop methods to analyze a
considerable amount of geographically referenced data and
identify risk factors most likely to be associated with birth defects.
EPHI researchers investigated associations between birth defects and mothers' proximity to industrial releases
of chlorinated solvents.37 These solvents are widely used in industrial processes, including metal degreasing, dry cleaning,
and production of pharmaceuticals, pesticides, and adhesives. The birth defects they evaluated included neural tube, oral
cleft, limb deficiency, and congenital heart defects for a large study population—the largest at the time of publication.
The study results indicated that mothers' residential proximity to several chlorinated solvent air emissions are associated
with neural tube, oral cleft, and congenital heart defects, especially among children of older mothers.
The researchers also validated a model—the Emission Weighted Proximity Model (EWPM)—that is a simpler and less
expensive way to estimate air pollution exposure intensities.38 They compared EWPM to National-Scale Air Toxics
Assessment estimations with ground air quality monitoring data collected by the Texas Commission on Environmental
Quality. These results indicated that the EWPM is a valid alternative approach for cases where epidemiological analysis
requires environmental data and health outcome data for a large geographic area and over multiple years.
Q The weighting of emissions from multiple point sources using distance was a significant advancement. Most
studies in the past have used emissions from the nearest point source or some other basic approach.
Results
"The methods can be widely used in environmental health research. The exposure dataset
may be useful for researchers to analyze in the future. The visual analytics approach
developed by this project is a novel approach to examination of the association between
health outcome and multiple exposures, one that holds considerable promise."
- F. Benjamin Zhan, PhD, Texas State University
Indicators of Health Outcomes Related to Air Pollution
Asthma and other Respiratory Effects Indicators
EPHI investigators at the New York University School of Medicine and New York City Department of Health and Mental
Hygiene, led by Dr. Kazuhiko Ito, aimed to improve the accuracy of near real-time surveillance of asthma exacerbations.
They sought to determine whether emergency department (ED) visits for asthma based on subjects' chief complaints
data, which is available the day after an ED visit, was correlated with physician-diagnosed asthma ED visits and asthma
hospitalizations (data not available as quickly).
g EPHI investigators evaluated New York City data and found that data from symptom observations (e.g., asthma-
and cardiovascular-related ED visits) were correlated with physician-diagnosed asthma ED visits and asthma
hospitalizations.39 They also found asthma ER visit and hospitalizations were correlated with weather and air pollution
variables. Their results showed that within-city asthma morbidity was temporally associated with daily variation in air
pollution measures—all three air pollutants they evaluated (PM2.5, nitrogen dioxide, and ozone) were positively and
significantly associated with asthma ED visit counts. Asthma was also spatially associated with socioeconomic factors (e.g.,
poverty) and environmental factors (e.g., residential proximity to traffic).
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DRAFT EPHI Impact Report - March 2018
Findings (New York University School of
Medicine, New York City of Health and Mental
Hygiene, University of California - Los Angeles,
and University of California - Berkeley)
Confirmed feasibility of new health outcome
indicators:
• asthma-related emergency
department (ED) visits,
• absences from school/work,
• medication use,
• frequent asthma symptoms, and
• asthma-like symptoms among those
without asthma diagnosis.
Impact
This research demonstrated that data on asthma ED visits
(available a day after a visit) is a good indicator of physician-
diagnosed asthma ED visits and reasonable indicator of physician-
diagnosed asthma hospitalizations. This indicator validation and
associated analysis supports the identification of at-risk populations
for asthma.
An EPHI grant to the University of California at Los Angeles and at
Berkeley, led by Dr. Ying-Ying Meng, explored the feasibility of
combining existing environmental monitoring data and California
Health Interview Survey (CHIS) data to develop health outcome
indicators of breathing problems. They considered people who have
been diagnosed with asthma and those who have not.
Results
EPHI researchers developed long-term criteria air
pollutant exposure indicators using measurement data for ozone,
nitrogen dioxide, and course and fine particulate matter from
California Air Resource Board (CARB) air monitors for CHIS 2003 and
2005 respondents.40 They identified positive associations between
exposures to criteria air pollutants and health effects for people with
asthma. Health outcome indicators such as asthma-related ED visits,
absences from school/work, medication use, and frequent asthma
symptoms may serve as a new set of health indicators for ozone,
particulate matter, and nitrogen dioxide exposures. The researchers
also observed associations between exposure estimates for criteria
air pollutants and asthma-like health outcomes among those
without asthma, diagnoses, including wheeze symptoms, having
two or more wheeze attacks, and seeking medical help for breathing problems. They used geostatistical modeling to
develop exposure indicators. For the CHIS 2003 respondents, they observed positive associations between asthma health
outcomes and these new exposure indicators for nitrogen oxide, nitrogen dioxide, and nitrogen oxides.
Impact
New health outcome indicators for criteria pollutant exposures were identified for people with and without asthma
diagnosis. Geostatistical modeling-based exposure indicators show promise for improving the accuracy of pollutant
assessment compared to indicators based on air monitoring data alone. This conclusion is particularly relevant for traffic
emissions exposures. The research grant also identified community-level health impacts in California and differences in
health outcomes across racial/ethnic groups that add to the scientific evidence supporting policy decisions at the local,
state, and national levels.
Cardiovascular Effects Indicators
Reducing the burden of heart disease and stroke has been
challenged by many factors. Among them are gaps in understanding
of environmental factors that predispose individuals to plaque
rupture and factors associated with cardiovascular disease. An EPHI
research collaboration project between the Lovelace Biomedical and
Environmental Research Institute and the University of New Mexico,
led by Dr. Matthew Campen, characterized the progression of
atherosclerosis associated with exposure to ambient environmental
air pollutants to identify more robust indicators of exposure.
Results
The EPHI researchers used animal models and human
studies to identify markers of air pollution-induced toxicity to the
cardiovascular system. They investigated mechanisms of the effects from exposures to important air pollutants, alone and
in combination. Highlights of their findings include the following,
¦ Rats exposed episodically via inhalation for 16 weeks to ozone or diesel exhaust particulates exhibited induced
aortic and cardiac molecular alterations.41
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DRAFT EPHI Impact Report - March 2018
Studies iri mice generated findings that identify a specific cellular receptor—oxidized low-density lipoprotein
receptor—as a possible mediator of air pollution-induced progression of cardiovascular disease.42
Evaluations of plasma collected from healthy human volunteers before and after exposure to diesel exhaust and
nitrogen dioxide suggest that exposure to diesel or nitrogen dioxide can cause upregulation of proinflammatory
factors in the circulatory system.43
Impact
This research contributed significantly to improving the understanding of the mechanism underlying the well-
documented relationship between air pollution and cardiovascular mortality. The journal articles describing the findings
were cited between 35 and 58 times by other articles representing thirteen countries. The assays developed because of
the grant offer new approaches to assessing the cardiovascular risk associated with air pollution exposure. Dr. Campen
indicated this research directly supported current and more advanced scientific thinking regarding inflammatory
biomarkers. The new thinking is to develop a holistic screen of serum or plasma using a cell culture exposure approach.
They concluded that assessing the net functional balance of inflammation in serum is superior to a single or even several
inflammatory biomarkers. The researchers recently applied the approach for a tribal community living near abandoned
uranium mine sites in the Southwest, the results of which are being considered in prioritizations of mine site
remediation.44
"The outcome of this research was the development of a novel clinically- and
epidemiologically-viable tool for assessing the overall circulating inflammatory potential of
humans. This tool is being used currently to study individuals with disease (heart, kidney,
lung), as well as toxicological impacts of environmental exposures in communities."
- Matthew Campen, PhD, University of New Mexico
Immunological Effects Indicators
EPHI researchers at Stanford University, led by Dr. Kari Nadeau, studied T regulatory cells as an immunological indicator of
ambient air pollution exposure and asthma in children. T cells suppress immune responses that can lessen effects of
asthma.
Results
The research demonstrated ambient air pollution impairs T
cells, which leads to more severe asthma via an immune system
mechanism in asthmatic children. Impaired T regulatory cell function is
associated with ambient air pollution, including polycyclic aromatic
hydrocarbons, particulate matter, and ozone.45,46 This association is more
pronounced in individuals with atopic diseases, such as asthma or allergic
rhinitis.46
Findings (Stanford University)
Multiplex immunophenotyping is a
potential approach to identify specific
immune cell types and their response to
environmental exposures.
Identified on a cellular level, the impact of
air pollution on the immune functioning of
asthmatic children is detrimental.
Immune indicators help link environmental
exposures to disease outcomes, including
respiratory disorders, allergy, and asthma.
Impact
T regulatory cells are readily detected in blood samples and can
be monitored in both children and adults, making them a potentially
valuable indicator for long-term monitoring. Because T regulatory cells
are associated with other diseases, including cancer and autoimmunity,
they also could serve as a useful indicator for additional health outcomes.
Validation of the findings in a larger cohort of subjects across different
development timelines could support development of immunotherapies
to treat air pollution-associated asthma. The 2010 publication of these
results has been cited 138 times in the Web of Science Core Collection
with citations from 20 countries.
"This grant has supported research showing on a cellular
level the detrimental impact of air pollution on the
immune functioning of asthmatic children."
- Kari Nadeau, MD, PhD, Stanford University
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Indicators of Exposure to Air Pollutants
Mobility-based Air Pollution Exposure Indicators
EPHI researchers at the University of Minnesota, led by
Dr. Julian Marshall, tackled a source of uncertainty that
has challenged ambient air pollution epidemiological
studies of large populations. Accurately characterizing
exposure to outdoor pollution is difficult because people
tend to move around, which affects their concentrations,
or levels, of pollution exposures. Personal monitoring,
although more accurate, is expensive. Error can be
introduced if epidemiological studies do not account for
mobility—for example at work, school, or shopping-but
no one had studied this question before.
Results
The EPHI research team compiled data for two
study areas (Vancouver and Southern California) and
analyzed residence- and mobility-based estimates of
individual exposure to ambient nitrogen dioxide.47 They calculated the bias for scenarios when mobility was not
considered. They found that ignoring daily mobility contributes to negative bias in effect estimates. In addition, increasing
spatial variation of pollution estimates led to stronger negative bias. The negative bias strengthened with increased time
and distance spent away from the residence.
This EPHI research was the first to investigate the effect of relying on residence-only-based estimates of
outdoor air pollution levels instead of mobility-based measures for large epidemiological studies. Such studies will benefit
from incorporating mobility information in exposure estimates. The study publication was cited 67 times in publications
from 13 countries as of March 2018, according to Web of Science.
Integrated Mobile Source Indicators (IMSI)
Gasoline and diesel traffic emissions in urban areas can be significant
contributors to fine particulate matter, nitrogen oxides (NOx), and
carbon monoxide (CO) emissions. Humans are exposed to mixtures of
these and other pollutants, rather than one pollutant at a time. Georgia
Institute of Technology and Emory University researchers, led by Dr.
Armistead Russell, applied a multipollutant approach to indicator
development to see if the refined indicators are more likely to explain
associations with health outcomes.48
Results
The researchers used air quality monitoring data collected in
Atlanta from 1999 to 2004. They developed two sets of IMSIs.49 One
set—emission based—was based on analysis of pollutant emissions and
observed concentrations. The other—health outcome based—used a
sensitivity analysis, two-pollutant mixtures, and health outcome data.
Using routinely collected monitoring data, the researchers developed:
¦ An improved indicator for biomass burning by estimating the
fraction of potassium associated with biomass burning based on a linear
regression with iron; this measure had a significantly better correlation
with an organic tracer of biomass burning compared to total potassium,
which is also found in soil dust and sea salt;50
¦ A method to better estimate secondary aerosol fraction of
particulate matter;51 and
¦ Specific source indicators for the impacts of mobile sources that
allowed characterization of diesel and gasoline vehicle impacts,
separately.
Findings (Georgia Institute of Technology)
IMSI agreed well with observed trends of
traffic.
Emission-based IMSI have stronger
associations with emergency department
visits for cardiovascular diseases, possibly
due to their better spatial
representativeness.
A multipollutant framework is more
informative to understanding health risk
from mobiles source emissions than using
single pollutant indicators.
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The health outcome data they evaluated was cardiovascular disease ED visits. They assessed short-term effects of these
pollutant pairs by looking at the daily measure of the indicator to see if it predicts that same day's cardiovascular disease
count. The emission-based IMSI for gasoline and diesel vehicles showed statistically significant associations as a predictor
of cardiovascular disease-related ED visits in the model.
y IMSI can be used in epidemiological analyses and in assessing the impact of mobile sources on emissions, air
quality, and health outcomes. These indicators are useful for cost-benefit analysis of air pollution reduction. The IMSI
indicators enable greater differentiation of particulate matter sources using routine monitoring data. Compared with
individual environmental indicators, IMSI are better indicators of regional impacts of mobile sources. This multipollutant
framework is a useful tool for cost-benefit analyses of air pollution reduction policies.
Traffic Exposure Indicators
Traffic is a source of a wide variety of air pollutants, including gases, metals, diesel
particles, and other particles of diverse size and chemical composition. Traffic also
produces noise, heat, and water vapor. Studies have identified associations between
exposure to traffic and health effects, including asthma, low birth weight, respiratory
disease, cardiovascular disease, and developmental deficits.52 The EPHI grant to the
Minnesota Department of Health, Minnesota Pollution Control Agency, and Olmsted
Medical Center, led by Dr. Jean Johnson, researched novel methods including using
geographic information system (GIS) and telecommunications global positioning
system (GPS) technologies to quantify exposure to traffic.
Results
To develop a new indicator of exposure to traffic density, EPHI researchers
used GIS data to calculate traffic density for the state of Minnesota and combined
these data with cell phone telecommunications GPS data that records activities and
travel patterns to develop a spatially resolved surface or representation of traffic
density.53 Exhibit 11 shows a street map of central Minneapolis-St. Paul depicting a 54-minute bicycle ride path, color
coded according to traffic density.
Exhibit 11. A bicycle ride path in central Minneapolis-St. Paul, Minnesota, color coded by traffic density
exposure, with green indicating lower traffic density and red indicating higher traffic density; inset
graph shows the density values over time.53
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^ The method integrates the deleterious effects of traffic rather than focusing on one specific pollutant at a time
and allows integration of exposure over the course of an individual's travel or along a travelled route. This approach
better characterizes exposure to air pollution and can be useful in future studies correlating exposure to air pollution with
observed health effects.
^ The traffic density calculation the EPHI researchers developed compared well with other measures of traffic
exposure. This exposure indicator combines effects of multiple stressors associated with traffic, which is advantageous to
single-pollutant assessments. The measures of traffic exposure over time generated can be used as an indicator to
evaluate health outcomes, for example, as a predictive variable in epidemiological studies. The methodology has potential
applicability for other environmental exposure assessment efforts.
Drinking and Surface Water
On average across all ages, people drink 0.9 liters of water daily.54 Water is essential to life, but it can also be a potential
exposure pathway for contaminants and microbial pathogens. Described here are three research projects by EPHI
grantees that developed indicators related to drinking water or recreating in surface waters.
Results
After gathering health data from approximately 500
people, EPHI researchers used GIS methods to predict arsenic
groundwater concentrations near the homes of the study subjects,
which then were validated with traditional sampling methods.56
Groundwater arsenic concentrations ranged from 2.2 to 15.3 ng/L;
as the current EPA standard for arsenic is 10 ng/L, these
concentrations are considered low level.59 They found that a
history of coronary heart disease was associated with increased GIS-estimated levels of groundwater arsenic.
Hypertension, a heart disease risk factor, also was associated with higher exposure to groundwater arsenic at the
estimated low levels.
Arsenic Drinking Water Exposure and Heart Disease Indicators
Each year, 25 of every 100 deaths in the U.S. are attributable to
heart disease—approximately 610,000 people.55 Over half
(approximately 370,000 people) are due to coronary heart disease,
the most common type of heart disease. The risk factors for heart
disease, which include high blood pressure (hypertension), high
cholesterol (hyperlipidemia), and smoking, are well-established and
extremely common; around 47% of the American population has at
least one of the three primary risk factors.55 The risk of heart
disease is doubled for individuals with hyperlipidemia.56 In addition
to health concerns, economic costs are associated with heart
disease and its risk factors; hypertension alone costs the U.S.
approximately $46 billion per year in healthcare services,
medications, and missed days of work.57 Given these extensive
health and economic considerations, identifying and understanding
the environmental elements contributing to heart disease and risk
factors of heart disease are important. Through research funded by
an EPHI grant led by Dr. Sid O'Bryant, researchers at Texas Tech
University provided the first demonstration that coronary heart
disease is associated with increased exposure to low-level
groundwater arsenic.58
These findings lend support to the proposition that increases in heart disease mortality are the result of
increased risks of coronary heart disease and its risk factors (i.e., hypertension) associated with higher low-level arsenic
exposure. The research contributions have important implications for national strategies to decrease the incidence of
heart disease.
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Mercury Exposure Indicator that Considers Selenium
Selenium is an essential trace element. Selenium-dependent enzymes—
selenoenzymes—are important for brain, endocrine system, and eye
health. Mercury inhibits brain selenoenzyme activity. Developing
children are potentially at risk if their mothers eat foods that contain
more mercury than selenium, for example shark and whale meat. But
eating other kinds of ocean fish during pregnancy is associated with a 4-
to 6-point increase in child intelligence quotient and improved maternal
health. An EPHI grant to the University of North Dakota, led by Dr.
Nicholas V. Ralston, developed an indicator that more accurately
considers the interactions between selenium and mercury to improve
risk assessment and management of mercury.
Results
EPHI investigators enhanced the reliability of a national-level
indicator called selenium health benefit value (HBVse) that considers
both methyl mercury exposure and dietary selenium intake focusing on
pregnant women's consumption.60 This indicator is a conservative index
that predicts effects of maternal methyl mercury exposures from
seafood consumption. They compiled mercury and selenium
concentrations and calculated HBVse results for more than 13,000 ocean
and freshwater fish and shellfish. Exhibit 12 shows results for selected
seafood. They found that most freshwater and ocean fish contain more selenium than mercury. Consuming these types of
fish is anticipated to be beneficial instead of harmful.
Exhibit 12. Comparison of seafood HBVSe values. Consumption of seafood with positive HBVse would negate risks associated with
methyl mercury exposures. Although intermittent methyl mercury exposures are unlikely to compromise maternal or fetal selenium
status, consistent consumption of negative HBVse seafood could have risks, especially among mothers with poor selenium intakes.
The HBVse provides information that confirms FDA and EPA advice for pregnant and breast-feeding women regarding seafood
ingestion.60
Pilot Whale
Mako Shark
Swordfish
Thresher Shark
Chinook Salmon
Coho Salmon
Albacore Tuna
Bigeye Tuna
Yellowfin Tuna
Skipjack Tuna
HBVSe = (uMSe -uM MeHg ) x (|iM Se + |iM Hg)
|iM Se
Negative HBVSe = Harmful
Positive HBVSe = Beneficial
-90
-60
-30
30
HBV,
Se
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"We are now able to solve mercury related problems in fresh water bodies using natural,
safe, and inexpensive approaches that better protect human and wildlife that eat fish from
these lakes and rivers."
- Nicholas Ralston, PhD, University of North Dakota
gThe HBVse indicator provides a more reliable and objective index for assessing relative effects of exposures to
methyl mercury. The indicator can help improve epidemiological and toxicological studies of methyl mercury by
considering selenium, ingestion of which counteracts adverse effects of maternal methyl mercury exposures on selenium
availability in fetal brains, thus contributing to improved health outcomes. The HBVse indicator provides a reliable, easily
understood, and consistent index for identifying healthy seafood choices. Application of the new indicator might enable
many fresh water bodies in the U.S. to no longer be under restriction regarding mercury content of the fish caught there.
The indicator also enhances how we respond to mercury risks where they do exist and helps to assess actual impacts of
environmental risk management resolutions. The information is also important for freshwater fish from regions with
selenium-poor soils. The indicator can be used for long-term tracking and surveillance of environmental public health,
which will promote better-informed decisions and recommendations on fish consumption. The results of this and other of
their work presented in two of their publications58,61, have been cited over 60 times by researchers in publications from
29 countries.
In addition, this research provided essential information captured in "Fish Issue Fact Sheets" (available at http://net-
effects.und.edu/factsheets.aspx) developed to inform the public and clinicians and scientists about the benefits of eating
fish and the importance of considering selenium as well as mercury content when evaluating exposures. Information from
this project has also been shared with the United Nations' Food and Agriculture Organization, at international meetings in
Sweden, and with European food safety agencies in Brussels and Paris and groups in Spain. The HBVse is rapidly becoming
a risk assessment criterion for agencies around the world.
Indicators of Exposure to Perfluorooctanoic Acid
Perfluorooctanoic acid (PFOA) is an industrial chemical
used to produce other perfluoroalkyl substances used in
coatings that are stick- and stain-resistant, water-resistant
coatings, food wrapping, firefighting foams, metal plating,
semiconductors, photographies, and photolithographies.
PFOA has been used widely in the past several decades
and is very environmentally persistent. Because of this,
PFOA and other perfluorinated chemicals, known as per-
and polyfluoroalkyl substances (PFAS) are quite prevalent
around the world and are detectable in living organisms,
including humans. Concern over effects from PFOA
exposures led to it being included on the most recent
Contaminant Candidate List, CCL-4, under the Safe
Drinking Water Act and finalized on November 17, 2016.
This is a list of contaminants that are currently not subject
' — — — to any national primary drinking water regulations, but are
known or anticipated to occur in public water systems.62 There is evidence that exposure to PFAS can lead to adverse
human health effects. The most consistent findings from human epidemiology studies are increased cholesterol levels
(i.e., is hypercholesteremic) among exposed populations63. Abnormal levels of cholesterol in the blood are associated
with the risk of heart disease. An EPHI grant to the University of Cincinnati and Harvard School of Public Health, led by Dr.
Susan Pinney, investigated biological and exposure PFOA indicators in the mid-Ohio River Valley. This area is of concern
due to historical industrial discharges of PFOA into the Ohio River, which contaminated water systems downstream.
g EPHI researchers measured perfluorinated chemical levels in preserved serum from three existing cohorts, one
of which featured samples collected for 18 years (1991 to 2008).64 Human exposure to PFOA has occurred throughout the
Mid-Ohio River Valley as indicated by serum concentrations above U.S. population levels in samples collected as early as
1991. The earliest serum samples (1991 to 2003) had the highest PFOA concentrations after adjusting for other factors.
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Serum PFOA levels were significantly associated with water source, sampling year, age at sampling, tap water
consumption, pregnancy, gravidity, and breastfeeding.
3This study is the first to characterize serum concentrations of PFOA in samples obtained as early as 1991 with
the benefit of study participant water supply source information. The results suggest that where serum PFOA was
elevated in the mid-Ohio River Valley community, drinking water was a primary source of exposure. The EPHI research in
combination with other research funding sources ultimately led to a revised water treatment practice in the Greater
Cincinnati area. Evidence was accumulating that higher exposures to perfluorinated chemicals were occurring in the area.
The researchers informed local water departments of the serum concentrations they had measured because of the EPHI
grant. In response, by 2012 the Greater Cincinnati Water Works implemented granular activated carbon filtration at both
their plants to meet new federal regulations and prepare for future regulations. They also considered the biomarker
information in determining the appropriate frequency for reactivating their granular activated carbon filters.
"PFOA exposure to humans was widespread throughout the Mid-Ohio River Valley
as indicated by serum concentrations above U.S. population levels in samples
obtained as early as 1991. Drinking water from the Ohio River and Ohio River Aquifer,
primarily contaminated by releases 209-666 kilometers upstream,
is likely the primary exposure source."
-Susan Pinney, PhD, University of Cincinnati
Waterborne Pathogen Indicators for Recreational Waters
identified microbial measures of water quality that could be used
protection.
An estimated 87.2 million people visited U.S. beaches
in 2003.65 A goal of the Clean Water Act is to ensure
the nation's waters are suitable for recreational
activities. These activities include full contact activities
such as swimming and snorkeling, and incidental
contact activities such as boating, kayaking, and
fishing. Recreation on our nation's beaches is
sometimes threatened by an overabundance of
microbial pathogens that can lead to illness among
beachgoers. The effects of beach closures can be
particularly intense for some communities where the
beach is an important source of tourism income for
the local economy. An EPHI grant to University of
Illinois at Chicago, MycoMetrics, and USGS Biological
Resources Division, led by Dr. Samuel Dorevitch,
in beach monitoring to improve public health
jjjjg The research team generated several important findings related to water quality indicators.
¦ They evaluated microbial measures of water quality—including viruses (coliphages) and the protozoan pathogens
Giardia and Cryptosporidium species—as predictors of gastrointestinal illness occurrence among recreators who
had incidental contact with the water.66 They developed a novel estimate of exposure—the estimated dose of
indicators and pathogens—that accounted for both volume of water ingested and density of microbes in water.
The study determined that measures of water quality, for example, pathogen densities, were not useful as
predictors of the occurrence of acute gastrointestinal illness. Compared to other secondary incidental activities,
fishing appears to be associated with a higher risk of illness, possibly due to the additional microbes on bait and
fish. They also observed an association between decreased incidence of illness and frequent use of a water
recreation location and recreating without exposing the face to the water.
¦ Prior epidemiological studies of water quality indicators and health have not considered severity of illness. To
address this question, EPHI researchers evaluated measures as predictors of gastrointestinal iliness severity among
swimmers using data from the National Epidemiological and Environmental Assessment of Recreational Water
(NEEAR) study and the Chicago Health Environmental Exposure and Recreation Study (CHEERS).67
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¦ They determined that a rapid water quality indicator method developed by EPA (enterococci DNA measured by
quantitative polymerase chain reaction [qPCR]) predicted gastrointestinal illness severity better than conventional
methods they evaluated.68
¦ The EPHI researchers also estimated costs of gastrointestinal illness attributable to water recreation (see Exhibit
13).69 They relied on data from the NEEAR and CHEERS studies.
"This grant research has led to significant improvements in water quality monitoring in the Chicago
area. The public now receives information about hazardous levels of bacteria within a few hours,
rather than the following day."
- Samuel Dorevitch, PhD, University of Illinois at Chicago
Exhibit 13. Estimates of costs of gastrointestinal illness attributable to water recreation (2007 U.S.
dollars).67
$1,676
for every 1,000-people engaged in swimming or wading at freshwater and marine
beaches in six states (NEEAR study data).
$1,220
for every 1,000-people engaged in incidental contact recreation including canoeing,
kayaking, fishing, rowing, or paddling in the Chicago area (CHEERS study data).
QiiEnBThis EPHI project has several impressive impacts. The researchers completed the first epidemiological study of
water recreation to evaluate measures of protozoan parasites as predictors of illness. They identified a superior water
quality detection method that adds value as an environmental public health indicator for beach managers. The findings
help focus efforts to reduce risk and associated costs, for example, education efforts about the hazards of swallowing
water and promoting hand washing to decrease exposure in those who fish could decrease risk of gastrointestinal illness
following incidental contact with recreational waters. The cost of illness information can be used to understand the
benefits of beach monitoring programs, costs of improving stormwater and wastewater infrastructure, and other
interventions to reduce the burden of illness associated with recreation in surface waters.
The research led to implementation of an improved beach monitoring program for Chicago beaches. For many years the
Chicago Park District used a culture method for E. coli testing. That method required at least 18 hours. The EPHI research
focused on the evaluation of rapid methods, including the DNA-based qPCR method, which can generate results within
hours. The Chicago Park District manages beaches that experience approximately 20 million visits per summer. They
recognized that the qPCR method can generate results more quickly than the culture method. During the summers of
2015 and 2016, EPHI researchers started qPCR monitoring at the Chicago beaches. The program enables rapid notification
of the public, both online and at beaches, about hazardous conditions (i.e., high levels of indicator bacteria). The
information goes into a public data portal (https://data.citvofchicago.org/Parks-Recreation/Beach-Lab-Data/2ivx-
z93u/abou ) and is referred to as "DNA testing."
Multipathway Pollutant Exposure Indicators
Contaminants that persist in the environment are a cause for concern due to the potential for exposure via multiple
pathways—for example ingestion of drinking water and ingestion of food. Summarized here are two EPHI research
examples that examined exposures that could arise from more than one exposure pathway.
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Arsenic Exposure Indicators
Arsenic exposure continues to be a U.S. public health concern due
to exposures through nonregulated sources. Inorganic arsenic is
classified as a Group 1 human carcinogen and contamination of
drinking water has been linked to cancers. Monitoring of arsenic in
food has focused typically on total arsenic because arsenic in food
is thought to be usually organic and not toxic. Knowledge of
arsenic species in foods, however, is incomplete. Approximately
one-quarter of commonly consumed foods in the U.S. contains
measurable arsenic according to the U.S. Food and Drug
Administration Total Diet Study. EPHI researchers, led by Dr.
Jefferey Burgess, at the University of Arizona developed indicators
evaluating the contribution of dietary sources of arsenic dose and methylation.
g EPHI researchers analyzed data from four population studies—the National Human Exposure Assessment
Survey (NHEXAS), Arizona, the Arizona Border Study (an extension of NHEXAS-Arizona), the Binational Arsenic Exposures
Survey (BAsES), and the 2003-04 National Health and Nutrition Examination Survey (NHANES).70,71 Their models
addressed person-specific data for intake of food, use of multiple sources of water for drinking and cooking, and
concentrations of arsenic in urine, cooking and drinking water, and food samples (total and speciated arsenic where
possible). They found that dietary total and inorganic arsenic intake, both measured and modeled, was a significant
predictor of urinary total arsenic and was independent of household tap water arsenic concentrations either above or
below the EPA maximum contaminant level (MCL) at that time of 10 ppb (see Exhibit 14).
Exhibit 14. Proportion of aggregate inorganic arsenic intake among non-seafood eaters attributable to food and
water used for drinking and cooking, stratified by househoid tap water arsenic concentrations <10 ppb versus >10
ppb, in two study populations, NHEXAS-AZ and BAsES,71
BAsES-AZ
dietary
drinking water
cooking water
< 10 ppb > 10 ppb
100 -i
< 10 ppb > 10 ppb
ro
B0
01
1—
00
CUD
<
o
c
NHEXAS-AZ
The research results from this EPHI grant demonstrated that food is the primary source of exposure to inorganic
and total arsenic in most U.S. populations. These results might have influenced federal action levels for arsenic in rice, rice
products, apple juice, and other foods. Arsenic measured directly from food was found to be a better predictor of urinary
arsenic levels than modeled dietary arsenic estimates. Identifying the contributions of food, drinking water, and cooking
water to arsenic exposure provides important information needed to assess arsenic risks and establish protective policies.
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According to Web of Science, these two publications have been referenced a combined total of 36 times by citations
representing 16 countries (retrieved March 2018).
"This research also showed an independent relationship between dietary inorganic arsenic
and a biomarker linked to adverse health (MMP-9) in populations with low levels of arsenic
in drinking water (below 3 ppb). This is a novel finding that emphasizes the importance of
further research on potential adverse effects of arsenic exposure from food."
-Jefferey L. Burgess, PhD, University of Arizona
Organochlorine Exposure arid Type 2 Diabetes Indicators
The Mississippi Delta is a highly rural area with a history of intense
agriculture. It suffers from high poverty and shortages of health
professionals. An EPHI grant to Mississippi State University, led by
Dr. Janice Chambers, researched an association between exposure
to organochlorine (OC) insecticides and type 2 diabetes. The
Mississippi Delta region was selected because of the historical use
of high levels of OC insecticides and the prevalence of Type 2
diabetes among the population in that region.
Results
The EHPI researchers worked to develop and use a new
indicator to study linkage between soil residues of organochlorine
insecticides, levels of their stable metabolites/degradants in
people, and the occurrence of type 2 diabetes. Organochlorine pesticides were heavily used for agriculture in the 1950s
and 1960s. Residues of DDE—a stable metabolite of DDT—are found in the U.S. and worldwide. The project focused on
the levels of DDE, the persistent metabolite of the heavily used insecticide DDT. The researchers sampled soils and blood
levels of DDE in two areas of Mississippi, the Mississippi Delta and a nonagricultural area that would have had a much
lower use of DDT and has a lower prevalence of type 2 diabetes (the non-Delta).72
What is diabetes?
Diabetes is a chronic disease that affects how the body turns food into energy.73 Most food is broken down into
sugar (also called glucose) and released into the bloodstream. The pancreas makes a hormone called insulin, which
lets blood sugar into cells to use as energy. People with diabetes either do not make enough insulin or cannot use
insulin as effectively. When enough insulin is not available or cells stop responding to insulin, the concentration of
sugar in the blood stream can be too high. Too much blood sugar over time can cause serious health problems, such
as heart disease, vision loss, and kidney disease.
Type 1 diabetes is caused by an autoimmune reaction (the body attacks itself by mistake) that stops the body from
making insulin. About 5% of the people who have diabetes have type 1.
With Type 2 diabetes, the body does not use insulin well and cannot keep blood sugar at normal levels. Most people
with diabetes—9 in 10—have type 2 diabetes. It develops over many years and is usually diagnosed in adults,
although increasingly in children, teens, and young adults.
The prevalence of type 2 diabetes increased in Mississippi from 9.5% to 12.3% from 2004 to 2008.
The U.S. prevalence of type 2 diabetes is 7.7%; in Mississippi it is 13.1%.
The researchers collected and analyzed soil samples. They found 10-times higher DDE levels in the Delta soil samples
compared to the non-Delta soils (see Exhibit 15). They analyzed blood samples and found about 1.5-fold higher blood
levels of DDE in the Delta study sample than in the non-Delta study sample. They found statistical associations between
higher levels of DDE and type 2 diabetes in the non-Delta study sample but not, however, in the Delta study sample,
counter to expectations. They also discovered that African Americans had higher blood DDE levels than Caucasians,
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DRAFT EPHI Impact Report - March 2018
which could be informative for future research identifying risk factors involved in the multiple health disparities
observed in African Americans.
Exhibit 15. Patterns of DDE concentrations in Mississippi.7
The Mississippi Delta population is unique from the standpoint of environmental sampling. The measurements
will add appreciably to the global literature that currently suggests that organochlorine compound levels are
biomarkers of type 2 diabetes risk. The data indicate the potential value of DDE as a biomarker of type 2 diabetes risk
for people who were exposed to low or moderate levels of DDT/DDE and could have utility in identifying those
individuals who should be targeted for extra lifestyle adjustments for maintaining health. DDE does not appear
appropriate, however, as a biomarker in highly exposed populations. The project has been delayed to comply with
important Institutional Review Board requirements, and manuscripts for submission to peer-reviewed journals are in
preparation.
"This research has identified the organochlorine compound DDE (the bioaccumulative
metabolite of the insecticide DDT) as a potential biomarker of risk (environmental
public health indicator) for type 2 diabetes in people who were exposed to only low or
moderate levels of DDT/DDE and may have utility in identifying those individuals who
should be targeted for extra lifestyle adjustments for maintaining health. However,
DDE cannot serve as a biomarker in highly exposed populations."
-Janice Chambers, PhD, Mississippi State University
Other Stressor Exposure and Health Outcome Indicators
Two non-chemical environmental stressor indicators tremendously important to community health were investigated by
EPHI program grants—pollen and heat. The research identified indicators linking these stressors with health effects, which
led to improved guidance to prevent disease and death.
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Pollen Exposure arid Allergic Disease Indicators
EPHI researchers at Mount Sinai School of Medicine collaborated with EPHI
investigators led by Dr. Kazuhiko at the New York School of Medicine to
investigate the association between pollen levels and population health
behaviors.
Results
EPHI researchers focused on assessing the association between
peaks in daily tree pollen concentrations and over-the-counter allergy
medication sales over a six-year period in New York City.74 The study used a
new minor illness surveillance approach incorporating a more direct
indicator of allergic disease that could capture the burden of illness more
accurately. The allergy medication sales align with tree pollen peaks (Exhibit 16).
y By following maple, oak, and birch tree pollen peaks, health departments can anticipate allergic responses and
improve public health advisories. Used in combination with meteorological forecast models, the indicator will facilitate
the creation of more specific pollen season charts and inform future projections of pollen-related morbidity. In 2013, the
New York City Department of Health and Mental Hygiene issued a health advisory to medical providers citing this EPHI
research. The City continues to provide health advisories that alert providers of the increased risk of pollen's exacerbation
of asthma in sensitive patients.
Exhibit 16. I ime-series plot of daily aiiergy medication sales; superimposed I
dates of tree pollen peaks color coded by tree type.74
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Heat-related Excess Mortality Indicators
Approximately 618 people in the U.S. are killed by extreme heat
every year.75 Older adults, the very young, and people with
chronic medical condition are at highest risk. However, even
young and healthy people can be affected if they participate in
strenuous physical activities during hot weather or fail to
adequately hydrate. Deaths from heat are not available for timely
surveillance during heat waves. The EPHI grant to the New York
School of Medicine and New York City Department of Health and
Mental Hygiene, led by Dr. Kazuhiko Ito, developed improved
indicators of heat-related illness.
Results
EPHI researchers investigated associations among daily weather conditions, heat-related ambulance calls and
ED visits, and excess natural-cause mortality in New York City.76 They analyzed data for May to September between 1999
and 2008. They observed that an 11% increase in natural-cause mortality was associated with an increase from the 50th
percentile to 99th percentile of same-day and one-day later heat-related emergency medical system calls and ED visits,
respectively. The study confirmed that tracking heat-related illness during heat waves using these syndromic-surveillance
indicators predict associated excess natural-cause mortality better than weather variables alone.
Impact
The study results contributed to the revision (i.e., lowering) of the National Weather Service heat advisory
threshold temperature for New York City. The guidance instructs that a Heat Advisory is issued when the heat index is
forecast to reach 95 to 99 degrees F for at least two consecutive days or 100 to 104 degrees F for any length of time.77
"The output from this project became useful for New York City Department
of Health's policies for air pollution, weather, and pollen."
- Kazuhiko Ito, PhD, New York School of Medicine
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DRAFT EPHI Impact Report - March 2018
For More Information
A searchable database of EPA STAR grant information, including publications and annual and final reports for
the EPHI grants is available at https://cfpub.epa.gov/ncer abstracts/index.cfm/fuseaction/search.welcome. These
EPHI grants are associated with the following EPA STAR grant requests for applications (RFAs):
• Development of Environmental Health Outcome Indicators (2006)
• Development of Environmental Health Outcome Indicators (2007)
• Exploring Linkages Between Health Outcomes and Environmental Hazards, Exposures, and Interventions for
Public Health Tracking and Risk Management (2009)
These EPHI grants were supported through EPA's Sustainable and Healthy Communities Research Program-
a customer-oriented, interdisciplinary research program that engages in direct communication with both internal Agency
partners and external stakeholders at the state and local (community) level to match scientific and technical expertise
with place-based environmental and related public health challenges. The program's focus is to provide the solutions,
tools, and other decision-support resources needed to meet Agency and partner statutory obligations, accelerate the
pace of contaminated site clean ups, and advance the understanding of the links between environmental quality, public
health, and human well-being. The largest and most diverse national research program within EPA's Office of Research
and Development, the program includes research in three broad categories: (1) technical and scientific support to clean
up and remediate contaminated sites; (2) understanding the flow of materials in order to reduce the generation of waste
and/or develop beneficial uses of waste; and (3) the development of solutions to revitalize communities impacted by
contaminated sites and those effected by natural disasters.
The heart of the program is the recognition that innovative, interdisciplinary environmental and public health research
can be done in ways that deliver solutions to the most pressing needs of our customers and partners while simultaneously
helping states and local communities align a healthy environment with sustained economic growth, public health, and
human well-being.
For more information, visit https://www.epa.gov/aboutepa/about-sustainable-and-healthv-communities-research-
program.
EPA has researched and developed a wide array of environmental and public health indicators. Examples
include:
• Report on Environment )ttps://cfpub.epa.gov/roe/
• America's Children and the Environment ittps://www.epa.gov/ace
• Climate Change Indicators https://www.epa.gov/climate-indicators
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DRAFT EPHI Impact Report - March 2018
Appendix A. EPHI Grants
The original abstract, annual reports, and final reports for these grants can be found by searching on the EPA's Grantee
Research Project Results website at: https://cfpub.epa.gov/ncer abstracts/index.cfm/fuseaction/search.welcome
EPA
GRANT
NUMBER
GRANT TITLE
PRINCIPAL
INVESTIGATORS & CO-
INVESTIGATORS
INSTITUTIONS
GRANT
AMOUNT
R833622
Statistical Models for Estimating
the Health Impact of Air Quality
Regulations
Franceses Dominici
Roger D. Peng
Marta Rava
Jonathan M. Samet
Ronald H. White
Scott L Zeger
Harvard T.H. Chan
School of Public
Health, The Johns
Hopkins University
$500,000
R833623
Near Real Time Modeling of
Weather, Air Pollution, and Health
Outcome Indicators in New York
City
Kazuhiko Ito
Robert Mathes
Thomas Matte
Kristina Metzger
Arthur Nadas
George D. Thurston
New York University
School of Medicine,
New York City
Department of
Health and Mental
Hygiene
$494,552
R833624
Impact of Emission Reductions on
Exposures and Exposure
Distributions: Application of a
Geographic Exposure Model
Julian D. Marshall
Gurumurthy
Ramachandran
University of
Minnesota School of
Public Health
$459,556
R833626
Development and Assessment of
Environmental Indicators:
Application to Mobile Source
Impacts on Emissions, Air Quality
and Health Outcomes
Armistead G. Russell
Lyndsey Darrow
Mitchel Klein
James Mulholland
Jorge Pachon
Jeremy Sarnat
Stefanie Ebelt Sarnat
Paige Tolbert
Georgia Institute of
Technology, Emory
University
$499,512
R833627
Measuring the Impact of
Particulate Matter Reductions by
Environmental Health Outcome
Indicators
Jean Johnson
Greg Pratt
Barbara Yawn
Minnesota
Department of
Health, Minnesota
Pollution Control
Agency, Olmsted
Medical Center
$488,650
R833628
The Detroit Asthma Morbidity, Air
Quality and Traffic (DAMAT) Study
Robert L Wahl
Stuart A. Batterman
Lorraine Cameron
Michael Depa
Kevin Dombkowski
Erika Garcia
Mary Lee Hultin
Anna Michalak
Bhramar Mukherjee
Elizabeth Wasilevich
Julie Wirth
Michigan
Department of
Community Health,
Michigan State
University, School of
Public Health and
College of
Engineering,
University of
Michigan
$499,777
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DRAFT EPHI Impact Report - March 2018
EPA
GRANT
NUMBER
GRANT TITLE
PRINCIPAL
INVESTIGATORS & CO-
INVESTIGATORS
INSTITUTIONS
GRANT
AMOUNT
R833629
Development of Exposure and
Health Outcome Indicators for
Those with Asthma or Other
Respiratory Problems
Ying-Ying Meng
Michael Jerrfett
Beate R. Ritz
Michelle Wilhelm
University of
California - Los
Angeles, University
of California -
Berkeley
$500,000
R833990
Novel Markers of Air Pollution-
induced Vascular Toxicity
Matthew J. Campen
Amie K. Lund
Lovelace Biomedical
& Environmental
Research Institute,
University of New
Mexico
$500,000
R833991
Longitudinal Indicators of Policy
Impact on Pollution, Exposure and
Health Risk
Thomas A. Burke
Mary A. Fox
The Johns Hopkins
University
$499,961
R833992
Modeling Dietary Contributions to
Arsenic Dose and Methylation:
Elucidating Predictive Linkages
Jefferey L. Burgess
Robin B. Harris
Paul Hsu
M. Elena Martinez
Mary Kay O'Rourke
Mel and Enid
Zuckerman College
of Public Health,
University of
Arizona
$499,999
R834786
Novel Immunological Approaches
to Link Ambient Air Pollution
Exposure to Health Outcomes
Kari Nadeau
Stanford University
$250,000
R834787
Assess the Linkage Between
School-Related Environment,
Children's School
Performance/Health, and
Environmental Policies Through
Environmental Public Health
Tracking
Shao Lin
Syni-An Hwang
The State University
of New York at
Albany, New York
State Department of
Health
$500,000
R834788
PFOA Concentration in Serum
Collected 1991-2008 and Related
Health Effects
Susan M. Pinney
Frank M. Biro
Robert Bornschein
Robert L. Herrick
Paul Succop
University of
Cincinnati
$499,980
R834789
Rapidly Measured Indicators of
Waterborne Pathogens
Samuel Dorevitch
Rebecca N Bushon
Salvatore Cali
King-Teh Lin
Li Liu
Peter Scheff
University of Illinois
at Chicago,
MycoMetrics, USGS
Biological Resources
Division
$499,831
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DRAFT EPHI Impact Report - March 2018
EPA
GRANT
NUMBER
GRANT TITLE
PRINCIPAL
INVESTIGATORS & CO-
INVESTIGATORS
INSTITUTIONS
GRANT
AMOUNT
R834790
Air Pollution-Exposure-Health
Effect Indicators: Mining Massive
Geographically-Referenced
Environmental Health Data to
Identify Risk Factors for Birth
Defects
F. Benjamin Zhan
Jean D. Brender
Peter H. Langlois
Jing Yang
Texas State
University, Texas A
& M Health Science
Center, Texas
Department of State
Health Services,
University of North
Carolina at
Charlotte
$499,987
R834791
Tribal Environmental Public Health
Indicators
Jamie Donatuto
Larry Campbell
Swinomish Indian
Tribal Community
$235,517
R834792
Fish Selenium Health Benefit
Values in Mercury Risk
Management
Nicholas V.C. Ralston
Laura Raymond
University of North
Dakota
$490,089
R834793
Using Vital Statistics Natality Data
to Assess the Impact of
Environmental Policy: The
Examples of Superfund, the Toxic
Release Inventory, and E-ZPass
Janet Currie
Princeton University
$492,103
R834794
Development and Validation of
the Cumulative Environmental
Exposure Index for Arsenic: A
Novel Environmental Public Health
Indicator
Sid E. O'Bryant
Gordon Gong
Leigh Johnson
Kevin R. Mulligan
Yan Zhang
Texas Tech
University Health
Sciences Center,
University of North
Texas - Health
Science Center at Ft
Worth, Texas Tech
University
$482,900
R834795
New Environmental Public Health
Indicator Linking Organochlorine
Compounds and Type 2 Diabetes
Janice E. Chambers
John Allen Crow
Matthew K. Ross
Robert W. Wills
Mississippi State
University - Main
Campus
$500,000
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DRAFT EPHI Impact Report - March 2018
Appendix B. Publications Attributed to EPHI Grants
Aggarwal, S., Jain, R., & Marshall, J. D. (2012). Correction to real-time prediction of size-resolved ultrafine PM on
freeways. ENVIRONMENTAL SCIENCE & TECHNOLOGY, 46(13), 7431-7432. doi:10.1021/es301825v
Aggarwal, S., Jain, R., & Marshall, J. D. (2012). Real-time prediction of size-resolved ultrafine PM on freeways.
ENVIRONMENTAL SCIENCE & TECHNOLOGY, 46(4), 2234-2241. doi:10.1021/es203290p
Barr, C. D., Diez, D. M., Wang, Y., Dominici, F., & Samet, J. M. (2012). Comprehensive Smoking Bans and Acute Myocardial
Infarction Among Medicare Enrollees in 387 US Counties: 1999-2008. AMERICAN JOURNAL OF EPIDEMIOLOGY,
176(7), 642-648. doi:10.1093/aje/kws267
Barr, C. D., & Dominici, F. (2010). Cap and trade legislation for greenhouse gas emissions: public health benefits from air
pollution mitigation. JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 303(1), 69-70. doi:doi:
10.1001/jama.2009.1955
Batterman, S. A., Zhang, K., & Kononowech, R. (2010). Prediction and analysis of near-road concentrations using a
reduced-form emission/dispersion model. Environmental Health, 9, 29. doi:doi: 10.1186/1476-069X-9-29.
Bell, M. L., Ebisu, K., Peng, R. D., Walker, J., Samet, J. M., Zeger, S. L., & Dominici, F. (2008). Seasonal and regional short-
term effects of fine particles on hospital admissions in 202 US counties, 1999-2005. AMERICAN JOURNAL OF
EPIDEMIOLOGY, 168(11), 1301-1310. doi:doi: 10.1093/aje/kwn252
Bobb, J. F., Dominici, F., & Peng, R. D. (2011). A Bayesian Model Averaging Approach for Estimating the Relative Risk of
Mortality Associated with Heat Waves in 105 U.S. Cities. Biometrics, 67(4), 1605-1616. doi:10.1111/j,1541-
0420.2011.01583.x
Brender, J. D., Shinde, M. U., Zhan, F. B., Gong, X., & Langlois, P. H. (2014). Maternal residential proximity to chlorinated
solvent emissions and birth defects in offspring: a case-control study. Environmental Health, 13, 96. doi:doi:
10.1186/1476-069X-13-96
Breslow, S. J., Sojka, B., Barnea, R., Basurto, X., Carothers, C., Charnley, S.,... Levin, P. S. (2016). Conceptualizing and
operationalizing human wellbeing for ecosystem assessment and management. Environmental Science & Policy,
66, 250-259. doi: 10.1016/j.envsci.2016.06.023
Campen, M., Lund, A., & Rosenfeld, M. (2012). Mechanisms linking traffic-related air pollution and atherosclerosis.
CURRENT OPINION IN PULMONARY MEDICINE, 18(2), 155-160. doi:10.1097/MCP.0b013e32834f210a
Chang, H. H., Peng, R. D., & Dominici, F. (2011). Estimating the acute health effects of coarse particulate matter
accounting for exposure measurement error. BIOSTATISTICS. doi:10.1093/biostatistics/kxr002
Channell, M., Paffett, M., Devlin, R., Madden, M., & Campen, M. (2012). Circulating factors induce coronary endothelial
cell activation following exposure to inhaled diesel exhaust and nitrogen dioxide in humans: evidence from a
novel translational in vitro model. Toxicological Sciences, 127(1), 179-186. doi:10.1093/toxsci/kfs084
Currie, J. (2011). Inequality at birth: some causes and consequences. AMERICAN ECONOMIC REVIEW, 101(3), 1-22.
doi:DOI: 10.1257/aer.l01.3.1
Currie, J. (2013). Pollution and infant health. Child Development Perspectives, 7(4), 237-242. doi:10.1111/cdep.12047
Currie, J., Davis, L., Greenstone, M., & Walker, R. (2015). Environmental health risks and housing values: evidence from
1,600 toxic plant openings and closings. AMERICAN ECONOMIC REVIEW, 105(2), 678-709.
doi: 10.1257/aer. 20121656
Currie, J., Graff, Z., JS, Meckel, K., Neidell, M., & Schlenker, W. (2013). Something in the water: contaminated drinking
water and infant health. Canadian Journal of Economics, 46(3), 791-810. doi:10.1111/caje.12039
Currie, J., Greenstone, M., & Moretti, E. (2011). Superfund cleanups and infant health. AMERICAN ECONOMIC REVIEW,
101(3), 435-441. doi: 10.1257/aer. 101.3.435
Currie, J., Ray, S., & Neidell, M. (2011). Quasi-experimental studies suggest that lowering air pollution levels benefits
infants' and children's health. Health Affairs, 30(12), 2391-2399. doi:10.1377/hlthaff.2011.0212
Currie, J., & Schwandt, H. (2015). The 9/11 dust cloud and pregnancy outcomes: a reconsideration. The Journal of Human
Resources, 51(A), 805-831. doi:10.3368/jhr.51.4.0714-6533R
Currie, J., Zivin, J., Mullen, J., & Neidell, M. (2014). What do we know about short- and long-term effects of early-life
exposure to pollution? ANNUAL REVIEW OF RESOURCE ECONOMICS, 6(1), 217-247. doi:10.1146/annurev-
resource-100913-012610
Darrow, L. A., Klein, M., Sarnat, J. A., Mulholland, J. A., Strickland, M. J., Sarnat, S. E.,... Tolbert, P. E. (2011). The use of
alternative pollutant metrics in time-series studies of ambient air pollution and respiratory emergency
department visits. J Expos Sci Environ Epidemiol, 21(1), 10-19. doi:10.1038/jes.2009.49
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DRAFT EPHI Impact Report - March 2018
DeFlorio-Barker, S., Wade, T. J., Jones, R. M., Friedman, L. S., Wing, C., & Dorevitch, S. (2016). Estimated Costs of Sporadic
Gastrointestinal Illness Associated with Surface Water Recreation: A Combined Analysis of Data from NEEAR and
CHEERS Studies. Environ Health Perspect, in press. doi:10.1289/EHP130
DeFlorio-Barker, S., Wade, T. J., Turyk, M., & Dorevitch, S. (2016). Water recreation and illness severity. Journal of Water
and Health, 14(5), 713-726. doi:10.2166/wh.2016.002
Dominici, F., Peng, R., Zeger, S., White, R., & Samet, J. (2007). Particulate air pollution and mortality in the United States:
did the risks change from 1987 to 2000? AMERICAN JOURNAL OF EPIDEMIOLOGY, 166(8), 880-888.
doi:10.1093/aje/kwm222
Donatuto, J., Campbell, L., & Gregory, R. (2016). Developing Responsive Indicators of Indigenous Community Health.
INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH, 13(9), 899.
doi: 10.3390/ijerph 13090899
Donatuto, J., Grossman, E., Konovsky, J., Grossman, S., & Campbell, L (2014). Indigenous community health and climate
change: integrating biophysical and social science indicators. COASTAL MANAGEMENT, 42(4), 355-372.
doi: 10.1080/08920753.2014.923140
Dorevitch, S., DeFlorio-Barker, S., Jones, R. M., & Liu, L. (2015). Water quality as a predictor of gastrointestinal illness
following incidental contact water recreation. Water Research, 83, 94-103. doi: 10.1016/j.watres.2015.06.028
Edwards, M., Hall, J., Gong, G., & O'Bryant, S. E. (2014). Arsenic exposure, AS3MT polymorphism, and neuropsychological
functioning among rural dwelling adults and elders: a cross-sectional study. Environmental Health, 13(1), 15.
doi:doi: 10.1186/1476-069X-13-15
Edwards, M., Johnson, L., Mauer, C., Barber, R., Hall, J., & O'Bryant, S. (2014). Regional specific groundwater arsenic levels
and neuropsychological functioning: a cross-sectional study. International Journal of Environmental Health
Research, 24(6), 546-557. doi:10.1080/09603123.2014.883591
Eftim, S. E., Samet, J. M., Janes, H., McDermott, A., & Dominici, F. (2008). Fine particulate matter and mortality: a
comparison of the six cities and American Cancer Society cohorts with a medicare cohort. Epidemiology, 19(2),
209-216. doi:10.1097/EDE.0b013e3181632c09
Falkowski, J., Atchison, T., DeButte-Smith, M., Weiner, M. F., & O'Bryant, S. (2014). Executive Functioning and the
Metabolic Syndrome: A Project FRONTIER Study. Archives of Clinical Neuropsychology, 29(1), 47-53.
doi:10.1093/arclin/act078
Flanders, W. D., Klein, M., Darrow, L A., Strickland, M. J., Sarnat, S. E., Sarnat, J. A.,... Tolbert, P. E. (2011). A Method for
Detection of Residual Confounding in Time-series and Other Observational Studies. Epidemiology, 22(1), 59-67.
doi:10.1097/EDE.0b013e3181fdcabe
Flanders, W. D., Klein, M., Darrow, L A., Strickland, M. J., Sarnat, S. E., Sarnat, J. A.,... Tolbert, P. E. (2011). A Method to
Detect Residual Confounding in Spatial and Other Observational Studies. Epidemiology, 22(6), 823-826.
doi:10.1097/EDE.0b013e3182305dac
Fox, M. A., Sheehan, M. C., & Burke, T. A. (2015). A risk assessment approach for policy evaluation: New Jersey case
studies. HUMAN AND ECOLOGICAL RISK ASSESSMENT, 21(8), 2258-2272.
doi: DOI: 10.1080/10807039.2015.1046982
Gilman, C. L, Soon, R., Sauvage, L, Ralston, N. V. C., & Berry, M. J. (2015). Umbilical cord blood and placental mercury,
selenium and selenoprotein expression in relation to maternal fish consumption. Journal of Trace Elements in
Medicine and Biology, 30,17-24. doi:http://dx.doi.org/10.1016/j.jtemb.2015.01.006
Gong, G., Hargrave, K., Hobson, V., Spallholz, J., Boylan, M., Lefforge, D., & O'Bryant, S. (2011). Low-level groundwater
arsenic exposure impacts cognition: a Project FRONTIER study. JOURNAL OF ENVIRONMENTAL HEALTH, 74(2),
16-23.
Gong, G., Mattevada, S., & O'Bryant, S. E. (2014). Comparison of the accuracy of kriging and IDW interpolations in
estimating groundwater arsenic concentrations in Texas. ENVIRONMENTAL RESEARCH, 130, 59-69.
doi:http://dx.doi.org/10.1016/j.envres.2013.12.005
Gong, G., & O'Bryant, S. (2012). Low level arsenic exposure, AS3MT gene polymorphism and cardiovascular diseases in
rural Texas counties. ENVIRONMENTAL RESEARCH, 113, 52-57. doi:10.1016/j.envres.2012.01.003
Gong, X., Zhan, F. B., Brender, J. D., Langlois, P. H., & Lin, Y. (2016). Validity of the Emission Weighted Proximity Model in
estimating air pollution exposure intensities in large geographic areas. Science of The Total Environment, 563-
564, 478-485. doi:10.1016/j.scitotenv.2016.04.088
Greven, S., Dominici, F., & Zeger, S. (2011). An Approach to the Estimation of Chronic Air Pollution Effects Using Spatio-
Temporal Information. Journal of the American Statistical Association, 106(494), 396-406.
doi:10.1198/jasa.2011.ap09392
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DRAFT EPHI Impact Report - March 2018
Hall, J., Edwards, M., Barber, R., Johnson, L, Gong, G., & O'Bryant, S. E. (2012). Higher groundwater selenium exposure is
associated with better memory: a Project FRONTIER study. NEUROSCIENCE & MEDICINE, 3(1), 18-25. doi:doi:
10.4236/nm.2012.31004
Herrick, R. L, Buckholz, J., Biro, F. M., Calafat, A. M., Ye, X. Y., Xie, C. C., & Pinney, S. M. (2017). Polyfluoroalkyl substance
exposure in the Mid-Ohio River Valley, 1991-2012. Environmental Pollution, 228, 50-60.
doi:10.1016/j.envpol.2017.04.092
Hew, K. M., Walker, A. I., Kohli, A., Garcia, M., Syed, A., McDonald-Hyman, C.,... Nadeau, K. C. (2015). Childhood
exposure to ambient polycyclic aromatic hydrocarbons is linked to epigenetic modifications and impaired
systemic immunity in T cells. Clinical & Experimental Allergy, 45(1), 238-248. doi:10.1111/cea.12377
Hew, K. M., Walker, A. I., Kohli, A., Garcia, M., Syed, A., McDonald-Hyman, C.,... Nadeau, K. C. (2015). Childhood
exposure to ambient polycyclic aromatic hydrocarbons is linked to epigenetic modifications and impaired
systemic immunity in T cells. Clinical and Experimental Allergy, 45(1), 238-248. doi:10.1111/cea.12377
Ito, K., Mathes, R., Ross, Z., Nadas, A., Thurston, G., & Matte, T. (2011). Fine particulate matter constituents associated
with cardiovascular hospitalizations and mortality in New York City. ENVIRONMENTAL HEALTH PERSPECTIVES,
119(A), 467-473. doi:10.1289/ehp,1002667
Janes, H., Dominici, F., & Zeger, S. (2007). Partitioning evidence of association between air pollution and mortality.
Epidemiology, 18(A), 427-428. doi:10.1097/EDE.0b013e318068647b
Janes, H., Dominici, F., & Zeger, S. (2010). On quantifying the magnitude of confounding. BIOSTATISTICS, 11(3), 572-582.
doi:10.1093/biostatistics/kxq007
Janes, H., Dominici, F., & Zeger, S. L. (2007). Trends in air pollution and mortality: an approach to the assessment of
unmeasured confounding. Epidemiology, 18(A), 416-423. doi:10.1097/EDE.0b013e31806462e9
Johnson, L A., Cushing, B., Rohlfing, G., Edwards, M., Davenloo, H., D'Agostino, D.,... O'Bryant, S. E. (2014). The
Hachinski Ischemic Scale and cognition: the influence of ethnicity. Age and Ageing, 43(3), 364-369.
doi:10.1093/ageing/aftl89
Johnson, L A., Gamboa, A., Vintimilla, R., Edwards, M., Hall, J., Weiser, B.,... O'Bryant, S. E. (2016). A Depressive
Endophenotype for Predicting Cognitive Decline among Mexican American Adults and Elders. Journal of
Alzheimer's Disease, 54(1), 201-206. doi:10.3233/JAD-150743
Johnson, L A., Hall, J. R., & O'Bryant, S. E. (2013). A Depressive Endophenotype of Mild Cognitive Impairment and
Alzheimer's Disease. PLOS ONE, 8(7), e68848. doi:10.1371/journal.pone.0068848
Johnson, L A., Phillips, J. A., Mauer, C., Edwards, M., Balldin, V. H., Hall, J. R.,... O'Bryant, S. E. (2013). The impact of GPX1
on the association of groundwater selenium and depression: a Project FRONTIER study. BMC PSYCHIATRY, 13,1.
doi:doi: 10.1186/1471-244X-13-7
Kielb, C., Lin, S., Muscatiello, N., Hord, W., Rogers-Harrington, J., & Healy, J. (2015). Building-related health symptoms and
classroom indoor air quality: a survey of school teachers in New York State. INDOOR AIR, 25(4), 371-380.
doi: 10.1111/ina. 12154
Kodavanti, U. P., Thomas, R., Ledbetter, A. D., Schladweiler, M. C., Shannahan, J. H., Wallenborn, J. G.,... Parinandi, N. L
(2011). Vascular and cardiac Impairments in rats inhaling ozone and diesel exhaust particles. ENVIRONMENTAL
HEALTH PERSPECTIVES, 119(3), 312-318. doi:doi: 10.1289/ehp. 1002386
Kohli, A., Garcia, M. A., Miller, R. L., Maher, C., Humblet, O., Hammond, S. K., & Nadeau, K. (2012). Secondhand smoke in
combination with ambient air pollution exposure is associated with increased CpG methylation and decreased
expression of IFN-y in T effector cells and Foxp3 in T regulatory cells in children. Clinical Epigenetics, 4(1), 17.
doi:doi: 10.1186/1868-7083-4-17
Kurzius-Spencer, M., Burgess, J. L, Harris, R. B., Hartz, V., Roberge, J., Huang, S.,... O'Rourke, M. K. (2014). Contribution
of diet to aggregate arsenic exposures[mdash]An analysis across populations. J Expos Sci Environ Epidemiol,
24(2), 156-162. doi:10.1038/jes.2013.37
Kurzius-Spencer, M., Harris, R. B., Hartz, V., Roberge, J., Hsu, C.-H., O'Rourke, M. K., & Burgess, J. L. (2016). Relation of
dietary inorganic arsenic to serum matrix metalloproteinase-9 (MMP-9) at different threshold concentrations of
tap water arsenic. J Expos Sci Environ Epidemiol, 26(5), 445-451. doi:10.1038/jes.2014.92
Kurzius-Spencer, M., O'Rourke, M. K., Hsu, C.-H., Hartz, V., Harris, R. B., & Burgess, J. L (2013). Measured versus modeled
dietary arsenic and relation to urinary arsenic excretion and total exposure. J Expos Sci Environ Epidemiol, 23(4),
442-449. doi:10.1038/jes.2012.120
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source apportionment approach for health studies. ENVIRONMENTAL SCIENCE & TECHNOLOGY, 43(18), 7023-
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