Children's Health Protection Advisory Committee Chair: Deanna Scher, PhD Environmental Health Division Minnesota Department of Health 625 N. Robert Street St. Paul, MN 55155-2538 (651) 201-4922 Deanna.Scher(5)state.mn.us Committee Members: Leif Albertson, MS Rebecca Bratspies, JD Lori G. Byron, MD, MS Jose Cordero, MD, MPH Natasha DeJarnett, PhD, MPH Diana Felton, MD Julie Froelicher, MEM Katie Huffling, DNP, CNM Peter Lee, MD, MPH Maureen Little, DrPH Linda McCauley, PhD Mark Miller, MD, MPH Olga Naidenko, PhD Ruth Ann Norton Daniel Price, PhD Virginia Rauh, SCD, MSW Perry E. Sheffield, MD, MPH Derek G. Shendell, D. Env., MPH Veena Singla, PhD Alicia Smith, PhD ShirleeTan, PhD Joyce Theard, MS KristieTrousdale, MPH Carmen M. Velez Vega, PhD, MSW Yolanda Whyte, MD Ke Yan, PhD, MS Marya Zlatnik, MD, MMS February 28, 2023 Administrator Michael Regan United States Environmental Protection Agency 1200 Pennsylvania Avenue, NW Washington, DC 20460 RE: America's Children and the Environment Report Dear Administrator Regan: The Children's Health Protection Advisory Committee (CHPAC) appreciates the opportunity to comment on the future direction of the America's Children and the Environment report and web portal (herein called ACE), which organizes and presents information on indicators3 of children's environmental health in the United States. The charge document provided by EPA asks for recommendations on three specific areas: content, visualization, and outreach (Appendix A). CHPAC's recommendations for each topic area are summarized in Appendix B. Historical and Current Context of ACE To respond to the specific charge questions, it is important to establish the principal goals of ACE. The background section of the charge question document, early ACE reports, and published articles emphasize the intent and historical importance of ACE as an agenda-setting mechanism and tool to support data- informed policy interventions to protect children's health in multiple areas.1"5 These documents also describe ACE as a national report card to document progress made in protecting children's health, as well as areas that warrant additional attention, potential issues of concern, and persistent problems. The CHPAC sees tremendous value in these goals; however, it is our perception that ACE is currently underutilized. One reason for this may be the advancement of related data tools outside of the Office of Children's Health Protection (OCHP). For example, the Centers for Disease Control and Prevention's (CDC's) National Environmental Public Health Tracking Network (EPHT) web-based data system includes a broad array of dashboards and visualizations and serves as an authoritative source for nationally consistent indicators and measures of environmental health, including many that focus on children.6"9 CDC has also funded certain state and local partners to collaborate on data acquisition and develop their own data portals.10 The national, state, and local EPHT portals are frequently used by public health programs, policymakers, researchers, and other users to monitor trends, design programs, inform health policy, and conduct studies and projects. a Indicators provide a summary of data on an aspect of children's environmental health in a relevant and understandable format. Children's Health Protection Advisory Committee is a Federal Advisory Committee for the U.S. Environmental Protection Agency under the Federal Advisory Committee Act https://www.epa.gov/children/chpac ------- Administrator Regan Page 2 February 28, 2023 EJScreen is another source of nationally consistent data and measures created by EPA's Office of Environmental Justice (OEJ) in 2010. This popular mapping tool enables assessment of differences in environmental health exposures and effects across geographies down to the U.S. census block group level.11,12 Data for indicators and environmental justice (EJ) index scores can be downloaded for further use. Several indicators speak directly to children's environmental health, such as "Individuals under age 5" and "Lead paint indicator". A major benefit of EJScreen is the ability to combine environmental, demographic, and socioeconomic indicators. Additional federal government reports also contain indicators of children's environmental health including EPA's Report on the Environment (ROE); CDC's Healthy People 2020 Report; and the America's Children Report published by the Federal Interagency Forum on Child and Family Statistics.13"15 These periodically updated reports include indicators that overlap with those currently in ACE, such as low birthweight, childhood cancer, and blood lead levels. Appendix C compares indicators in ACE with these other reports as well as EJScreen. Future Direction and Opportunities for ACE Moving forward, ACE must distinguish itself from existing data platforms and reports, reframe itself as an authoritative source of timely and relevant information on children's environmental health, and draw renewed attention to children's environmental health issues. To accomplish this, we recommend that ACE not only expand indicators and measures specific to children's environmental health but also contextualize, interpret, and disseminate this information in new ways. Providing data in interpretable formats will allow ACE to achieve the following objectives that speak to its original role: 1) fulfill the public's right to know about important environmental health issues of concern for children; 2) identify and highlight subpopulations of children at higher risk; 3) track national progress toward achieving a healthier environment for children; and 4) improve the public health basis for policymaking and guide intervention and prevention strategies for decision makers and affected parties at all levels. Through these efforts, CHPAC sees an opportunity for ACE to reframe the importance of the environment to children's health and elevate its overall visibility. This is especially important as climate change-related hazards increasingly threaten the health of children in the U.S.16 To support these goals, additional resources are needed for staffing and engagement activities. We recommend that EPA recruit additional staff with the skill sets needed to produce ACE (e.g., training in epidemiology to manage the systematic collection, integration, analysis, and interpretation of data; training in data informatics and visualization). These investments will be repaid by renewed focus on children's environmental health and increased awareness of the importance of protecting children's environmental health through prevention and intervention strategies. In sum, CHPAC offers the following broad recommendations for future updates and expansions of ACE: 1. ACE should distinguish itself from efforts of other data platforms and indicator reports by drawing explicit attention to, and contextualizing, children's environmental health issues; and, 2. ACE should receive additional resources, including funding and dedicated full-time employees with appropriate skill sets, to expand ACE and ensure that it reflects the current state of the science on children's environmental health and that data visualization and outreach strategies are properly implemented to maximize the report's utility and impact. ------- Administrator Regan Page 3 February 28, 2023 Charge Question 1- Enhancing Indicators CHPAC was asked to recommend important indicators that are currently missing from ACE, prioritize indicators, and advise EPA on current indicators or topics that should be retired. We recommend EPA develop a revised and expanded core set of indicators that is reviewed and updated on a routine basis. However, greatly expanding the current list of indicators, without a clear organizing principle, undercuts the overall children's environmental health framing and the agenda-setting function of the original ACE. Indicators should be screened for inclusion based on their contribution to the four goals of ACE described above and their ability to empower users to address issues affecting children's environmental health. Each of the following types of indicators plays an important role in characterizing how the environment affects children and should be represented in ACE: Environmental Hazards Environmental hazard indicators are physical, chemical, and biological factors in a child's environment; for example, substances in air or drinking water. ACE should prioritize hazard indicators that disproportionately impact children, such as chemicals in dust found on surfaces and carpets indoorsb or hazards in school and childcare environments. The table in Appendix D includes examples of potential hazard indicators that are not currently in ACE. Internal Exposures Internal exposure indicators are measures of substances in the body and body fluids from all exposure sources. EPA should maximize opportunities to characterize children's exposure by using biomonitoring data from CDC's National Health and Nutrition Examination Survey (NHANES). Unfortunately, data are not available in NHANES for many hazards of concern for children, younger children are often excluded from participating, and important matrices, such as breastmilk, are absent. In these cases, other data sources should be explored, even if they are not national in scope (e.g., state biomonitoring surveillance programs). When internal exposure measures are not available for chemicals of interest, ACE should highlight these gaps and include hazard indicators as measures of external exposure. Biomonitoring data within subpopulations of children at increased exposure risk (e.g., farmworker children) should also be factored into ACE as sub-indicators or in data stories. Health Outcomes Health outcome indicators should be prioritized by significance to the health and well-being of children. For example, while many government agencies currently report climate change indicators and measures, adverse outcomes focused on children are not well represented, such as number of school closure days due to wildfires and extreme weather events. Vulnerability This type of indicator focuses on magnitude of health disparity to highlight inequitable environmental pollution burdens among children. The ACE team may want to consider developing its own child vulnerability index - see the Child Vulnerability Index from the Center for Puerto Rican Studies as an example.17 Additionally, all indicators should be co-analyzed with b Young children play close to the ground and demonstrate mouthing behaviors, increasing their exposure to chemicals in house dust. ------- Administrator Regan Page 4 February 28, 2023 vulnerability indicators related to race/ethnicity and economic and social conditions. To increase actionability, these indicators or their accompanying content can quantify the degree to which disparities could be reduced if certain actions were taken. Gaps and Solutions There may be indicators deemed important to understand the state of children's environmental health that currently lack data sources for development. The ACE report can highlight these knowledge and data collection gaps to help spur needed research and surveillance activities. ACE should also consider indicators that focus on the implementation of solutions (e.g., policies, regulations, public health interventions) that address environmental health issues at national, state, tribal, and local levels. Changes in children's environmental health due to implemented solutions should also be emphasized across indicators through visualizations and contextualizing data stories. As a starting point for expansion, we provide a non-exhaustive list of indicator topics that are currently not in ACE for consideration (Table D-l in Appendix D). Appendix D also highlights broader areas that should be considered for further development in ACE, including indicators that focus on pregnancy as a vulnerable life stage, cumulative impacts, environmental health services and regulations to protect children, and incorporation of local-level data sources. EPA should develop and implement an iterative consensus process for indicator selection, prioritization, and retirement that includes input from partners identified in Charge Question 3. Meetings between the team of ACE staff, context experts at EPA, and external key partners, such as front-line or local experts, will enable bidirectional communication and increase user trust that ACE remains relevant to their needs. CHPAC can also serve a consultative role during both early and subsequent phases in the indicator selection process. EPA should strive to provide continuous web content updates to ACE while also providing time-stamped reports that can be archived for future understanding of the state of children's environmental health. Dynamic updates provide timely information while time-stamped reports enable users to see changes in measures and EPA approaches over time. ACE Special Issues Recognizing that the universe of potential indicators is extensive, a core set of indicators cannot cover all important children's environmental health topics without becoming unwieldy. One option is for EPA to develop "special issues" of the ACE report that include more in-depth reporting on specific, high priority topic areas. Bringing multiple streams of information on a topic together is a way to highlight a major issue and possible approaches for reducing impacts on children's health. Special issues can also serve as a mechanism to identify and elucidate emerging issues in children's environmental health by providing early warning of existing and potential threats to children's health and well-being. To this end, ACE could provide insight into an appropriate future research agenda by highlighting gaps in knowledge about emerging issues. Special issues on emerging issues could also lead to identification of indicators that would be important for regular reports or supplementary topics in ACE. The process to develop these special issues should be flexible. For example, they could be one-time reports or regularly updated, depending on need and topic. The reports could be written internally or ------- Administrator Regan Page 5 February 28, 2023 through convenings of relevant experts and interested parties to ensure proper characterization of data, knowledge gaps, and children's vulnerabilities. Each special issue could be the occasion for a new convening that could help create the larger and more engaged audience than ACE originally commanded. Three suggested topics for special issues (climate change, endocrine disrupting chemicals, and per- and polyfluoroalkyl substances) are described in Appendix E. Additional content accompanying indicators One of the main purposes of ACE is to "help policymakers, partners and the public track trends in children's environmental health and ultimately help identify and evaluate ways to minimize environmental impacts on children."18 Therefore, each indicator in ACE should be directly actionable or accompanied by additional content on relevant underlying and interdependent factors that point to ways to reduce impacts on children. For example, if EPA selects children's urine levels of organophosphate pesticide metabolites as an indicator, timepoints of key regulatory actions overlaid in visualizations (e.g., cancellation of chlorpyrifos residential uses and, most recently, food uses) can help contextualize the extent of resulting reduction in children's exposure. Pairing this indicator with levels of pesticides that have replaced, or are expected to replace, organophosphates (such as pyrethroids and neonicotinoids) over the same time period in available media (e.g., children's urine, or if not available, in food, drinking water, and/or house dust) presents a more complete story of children's exposure to insecticides over time and may demonstrate potential opportunities for further public health intervention. Another way to contextualize the information in ACE and highlight ways to reduce impacts on children is to include success stories about health-protective strategies that states, cities, and communities have adopted (e.g., decrease in insecticide use in a school district that implemented an integrated pest management program). To provide further context, ACE should also orient the reader to other available information and data tools related to each indicator. An appendix could be added to provide references and links to these additional resources. In sum, we recommend the following related to indicator selection in ACE: 1. EPA should develop an expanded core set of indicators that represents a balanced portfolio of indicator types. Indicators and measures should be reviewed and updated on a routine basis using an iterative and inclusive process. 2. ACE should be dynamic and routinely update certain aspects of its web presence while also providing time-stamped reports. 3. "Special issues" of the ACE report should be developed to supplement the core set of indicators and provide valuable information on specific topic areas. These special issues are a mechanism to deliver time-sensitive information about high-priority and/or emerging threats to children's health and to highlight gaps in understanding of children's exposures and health outcomes. 4. Indicators should be amenable to policy, environmental, and systems interventions at the local, state, tribal, and/or national levels. 5. Content accompanying indicators should provide context on contributing factors and ways environmental impacts on children can be minimized (e.g., success stories). Additional content to orient the reader to other available information and data tools related to the indicator topic is also suggested. ------- Administrator Regan Page 6 February 28, 2023 Charge Question 2 - Visualization and Analytic Approaches CHPAC was asked to provide recommendations on visualization and analytic approaches for ACE. We recommend that ACE offer a range of analytical and visualization framework options (e.g., interactive charts, trend visualizations, and downloadable tables) that can serve a variety of user needs. However, ACE should also use "straight-to-the-point" visualizations to highlight main findings, provide context, and maximize interpretability, especially for ACE audiences that do not have strong knowledge of the topic, the time, or the need for self-service visualization tools. For example, a simple time trend figure for one indicator may be a good way to highlight a concerning trend, while a plot that shows differences by subgroup may be useful to emphasize policy action opportunities. Data stories with visual components that accompany indicators/measures are another way to add context and illustrate how indicators intersect with people's lived experiences. Carefully constructed visual stories will be interpretable to multiple audiences and improve understanding of a topic's importance to children's environmental health. Ensuring the measures are available in different formats and that findings are interpretable will increase use of ACE among interested parties, including scientists, clinicians, policymakers, and the general public, which helps achieve the goals of ACE outlined above. Tools available for data visualization have greatly expanded in recent years, and there are many successful examples of visualization techniques that could be considered for ACE, both in-house and outside of EPA. For example, the Environmental Modeling and Visualization Laboratory at the EPA utilizes high performance computing to create specialized visualizations.19 These visualizations tell a scientific story and are used to humanize the effects of pollution, to engage a broader audience, and to point to new pathways for policy. Other fine examples include those published by EPA about indoor air quality;20,21 the March of Dimes Report Card on preterm birth;22 the CDC's Morbidity and Mortality Weekly Report;23 visualizations found in the digital tools accompanying research databases from the Pew Research Center;24 ProPublica's innovative air pollution data story;25 data stories developed by the University of Alabama at Birmingham and Dartmouth University;26,27 and data stories summarizing the global impacts from climate change published by the National Aeronautics and Space Administration.28 The California Department of Health's Community Burden of Disease Engine provides an engaging data toolset to display measures using interactive rankings, charts, maps and trend visualizations.29 The original ACE team viewed the report as a framework for understanding relationships between the environment and children's health.3 Data visualizations are one way to integrate environmental hazard, exposure, and health outcome measures to look at relationships or establish the case for further investigation or policy action. Considering ways to connect indicators, such as hazard and exposure indicators with health outcome and vulnerability indicators, through analytic approaches and visualizations should continue to be a prime consideration when feasible. To help create this more compelling version of ACE, CHPAC recommends enlisting a diverse group of data informatics, data analysis, visualization, user experience, and communication experts to help identify appropriate analytic approaches and visualizations. Sufficient resources should be allocated to develop internal expertise to create high quality and effective visualization and analytic approaches. EPA could contract with vendors to address any identified gaps in expertise. To determine whether analytic and visualization approaches are effective, feedback regarding the presentation and interpretability of the information should be solicited from different audiences as part of an evaluation process. ------- Administrator Regan Page 7 February 28, 2023 In sum, we recommend that: 1. Rather than one overarching visualization approach, the report should offer a range of visualization framework options that users can select to fit their own purpose. ACE should also include simple visualizations with associated content to highlight core findings and messages. 2. Indicator presentation should be designed to help organizations and communities contextualize key messages in ACE and focus their resources and efforts to improve the health and well-being of children. 3. Where possible, EPA should use visualizations to integrate different indicator types in order to identify and highlight relationships and increase actionability. 4. EPA should enlist experts in analytical methods, data informatics, visualization techniques, communication, user experience, and community engagement to support and strengthen the visualization program for ACE; and, 5. EPA should obtain feedback from difference audiences on the modes of presentation and their interpretability through an evaluation process. Charge Question 3 - Outreach EPA asked CHPAC for recommendations on audiences to prioritize for outreach to increase awareness and use of ACE, and effective means to publicize and disseminate ACE findings. Protecting and improving children's health and well-being is a shared responsibility across national, state, tribal, and local levels and within public, private, and not-for-profit sectors. These partners have a need for updated and relevant information on the state of children's environmental health, making outreach and engagement critical areas of work for ACE. Opportunities to increase dialogue with key audiences, including public health agencies and working groups, policymakers, professional organizations, health care providers, industries, and advocacy groups, should be pursued as part of ACE outreach activities. Engagement of interested parties will not only improve ACE products but also build trust and facilitate investment in partners' further dissemination of findings from the reports. While we recognize that such activities require a significant and ongoing investment of resources to be effective and sustainable, EPA has a well-established foundation of best practices, mechanisms, and tools for outreach to build upon. Outreach should take the form of bidirectional communication to set a framework for discussion about children's environmental health and create a space for the convergence of multiple perspectives and voices. Bidirectional communication should begin early in the indicator selection process and continue through the development of reports and their dissemination. Convenings during the development of core indicators and special issues, as suggested in the response to the first charge question, provide an early opportunity and concrete mechanism for bidirectional communication, which can be followed with additional public participation opportunities. Pediatric Environmental Health Specialty Units (PEHSUs) are key partners that could serve as a strong exemplar of bidirectional communication. PEHSUs are a national network of experts in the prevention, diagnosis, management, and treatment of health issues that arise from environmental exposures from preconception through adolescence. Currently, as PEHSUs become aware of emerging concerns in their regions, they must rely on networks of colleagues and the published literature to obtain information with which to advise their communities. In an ACE-PEHSU partnership, individual PEHSUs could provide input on indicator topics and data sources based on observed emerging concerns gathered through their local connections to an array of government, community, academic and health care partners within each of the 10 PEHSU regions. Likewise, EPA can provide outreach to PEHSUs on ACE findings related to issues ------- Administrator Regan Page 8 February 28, 2023 or health risks of concern within these regions. This bidirectional partnership would be beneficial, as currently, PEHSUs are sparsely funded (core funding is approximately 1.5 full-time staff per region and there is no funding to conduct research). Another group to engage in bidirectional communication is advocacy and community organizations. ACE findings should be shared with the White House's Environmental Justice Advisory Council and EPA's National Environmental Justice Advisory Council (NEJAC), each of which are largely comprised of community advocates who can help disseminate them. Similarly, the findings should be communicated to the Environmental Justice Coordinator in each of EPA's 10 regions and to as many of the State Environmental Justice/Community Outreach coordinators as possible with a directive to further disseminate the findings and any accompanying recommendations to community stakeholders within their jurisdictions. This should also be done with groups that represent rural areas (such as the Rural Community Assistance Partnership [RCAP]), cities (such as the National League of Cities [NLC]), and tribal areas. In this way, ACE findings can be shared as widely as possible, while feedback and recommendations from these groups should be encouraged and incorporated into ACE development. Decision makers at all levels (e.g., policy makers, regulators, agency staff) are one audience that should be prioritized to increase awareness and use of ACE. This audience is best poised to develop and implement prevention and intervention strategies in response to findings. Targeted outreach and messaging to decision makers can also address existing fragmentation of data sources on children's environmental health, both within and outside EPA, which is a current barrier to finding and accessing interpretable information needed to make health-protective decisions. Communications should emphasize the translation of ACE findings into public health actions. ACE could provide informational briefings for relevant EPA offices, working groups and state groups, such as the National Association of Chronic Disease Directors. ACE could also develop a short fact sheet or executive summary for each report that could be shared with legislators and other decisions makers around events like Children's Environmental Health Day in October. Finally, the experts in OCHP should present ACE findings at meetings and conferences with government attendees. Another audience to prioritize for dissemination of ACE findings is the scientific community, encompassing health care providers, epidemiologists, environmental health specialists and other scientists, researchers and academic health care institutions, and organizations that directly support scientific research through grants. In addition to the sharing of key findings, communication should emphasize gaps in data and research that limit understanding of children's environmental health risks. An effective and currently underutilized means to disseminate ACE findings to this audience is presentation at scientific conferences and publication in the scientific literature. Publications could focus on data collection and analysis methods, findings from more in-depth analyses (e.g., comparison of regional to national data), and scientific knowledge gaps. Two examples of how CDC has effectively communicated data and information to the scientific community can be found on their EPHT publications site30 and in their Morbidity and Mortality Weekly Report (MMWR). Indexing in PubMed has allowed the CDC's MMWR Series to reach many readers.23 In sum, we recommend that: 1. EPA dedicate more resources to ACE as an important outreach product and communication opportunity that requires investment in audience engagement and communication strategies. ------- Administrator Regan Page 9 February 28, 2023 2. ACE should actively engage with key audiences, such as PEHSUs and community and advocacy groups, using bidirectional communication starting early in the indicator selection process; and, 3. The scientific community and those in decision-making roles in government and private enterprise are important audiences to target for outreach efforts, as they are well positioned to address knowledge gaps and act upon ACE findings. Summary and Conclusions ACE was created to provide a holistic depiction of children's environmental health through indicators and measures, which does not currently exist within, and cannot be simply added to, the other existing tools noted in this response letter. Providing data and information elucidating existing and emerging threats to children's environmental health will underscore the responsibilities and ability of policymakers and other interested parties to act on behalf of vulnerable children. There is an opportunity for ACE to bring about meaningful improvements in children's environmental health by providing evidence that can be turned into actions. Contextualizing data by including messaging, simple visualizations and data stories that bring community experience of environmental risk to light will allow for a more convincing and actionable ACE report that renews attention to the need for scientifically grounded and community engaged decision-making across all levels of government and private activities. Even as the amount of available raw scientific data has increased, the understanding of those data and subsequent protective actions have been hindered by the lack of framing around children's environmental health vulnerabilities. The current convergence of new data visualization techniques and approaches for contextualization provides an opportunity for ACE to reclaim the agenda-setting and framing roles that it originally held. ACE can attract an invigorated audience by serving as a forum for diverse and historically excluded audiences in the children's environmental health space, as the definitive source for risks to children's environmental health, and as the facilitator of data-informed policy. CHPAC welcomes the opportunity to comment on a revised ACE during later stages of its development. Sincerely, y/ / . * - Deanna Scher, Ph.D. Chair cc: Grace Robiou, Director, Office of Children's Health Protection Amelia Nguyen, CHPAC Designated Federal Official, Office of Children's Health Protection ------- Administrator Regan Page 10 February 28, 2023 References 1. Environmental Protection Agency (EPA). America's Children and the Environment: A first view of available measures. U.S. Department of the Interior, Environmental Protection Agency, Office of Children's Health Protection and Office of Policy, Economics and Innovation, National Center for Environmental Economics; 2000. 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National Aeronautics and Space Administration (NASA). Vital signs of the planet: Carbon dioxide. Pasadena, CA: NASA's Jet Propulsion Laboratory, California Institute of Technology; 2022. https://climate.nasa.eov/vital-siens/carbon-dioxide/ 29. California Department of Public Health. California community burden of disease engine (CBB). California Department of Health; 2023. https://skylab.cdph.ca.gov/commynityByrden/ 30. Centers for Disease Control and Prevention (CDC). National Environmental Public Health Tracking: Publications. Atlanta, GA: U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Environmental Public Health Tracking; 2022. https://www.cdc.eov/nceh/trackine/pyblications.htm ------- Administrator Regan Page 12 February 28, 2023 31. Bennett D, Bellinger DC, Birnbaum LS, Bradman A, Chen A, Cory-Slechta DA, Engel SM, Fallin MD, Halladay A, Hauser R et al. Project TENDR: Targeting environmental neuro-developmental risks the TENDR consensus statement. Environ Health Perspect. 2016; 124(7):A118-A122. doi:10.1289/EHP358 32. Human Health Exposure Analysis Resource (HHEAR). Human Health Exposure Analysis Resource. 2023. https://hhearproerani.ore/ 33. Centers for Disease Control and Prevention (CDC). Austism Spectrum Disorder: Diagnostic Criteria. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2022. https://www.cdc.eov/iicbddd/aytisni/hcp-dsni.html 34. Davis EP, Narayan AJ. Pregnancy as a period of risk, adaptation, and resilience for mothers and infants. Dev Psychopathol. 2020; 32(5):1625-1639. https://doi.org/10.1017/S0954579420Q01121 35. Bekkar B, Pacheco S, Basu R, DeNicola N. Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US: A systematic review. JAMA Netw Open. 2020; 3(6):e208243.10.1001/jamanetworkopen.2020.8243 36. Rosen EM, Munoz Ml, McElrath T, Cantonwine DE, Ferguson KK. Environmental contaminants and preeclampsia: a systematic literature review. J Toxicol Environ Health B Crit Rev. 2018; 21(5):291- 319.10.1080/10937404.2018.1554515 37. Sheffield PE. Mental health and climate change: The critical window of pregnancy. Int J Gynecol Obstet. 2022; 160(2):383-384. https://doi.ore/10.1002/ijeo.14501 38. Etzel RA, Landrigan PJ. Children's exquisite vulnerability to environmental exposures In: Etzel RA, Landrigan PJ, editors. Textbook of Children's Environmental Health. Oxford, United Kingdom: Oxford University Press; 2013. p. 18-27. https://doi.org/10.1093/med/9780199929573.003.00Q2 39. Kennedy DA, Woodland C, Koren G. Lead exposure, gestational hypertension and pre-eclampsia: A systematic review of cause and effect. J Obstet Gynaecol. 2012; 32(6):512-517. https://doi.org/10.31Q9/01443615.2012.693987 40. Kriebel D, Tickner J. Reenergizing public health through precaution. Am J Public Health. 2001; 91(9):1351- 1355. https://doi.Org/10.21Q5/AJPH.91.9.1351 41. Hansen K, Hammer B. A fairer funding stream: How reforming the Clean Water State Revolving Fund can equitably improve water infrastructure across the country. New York, NY: Natural Resources Defense Council and Environmental Policy Innovation Center; 2022. R 22-09-A. https://www.nrdc.ore/sites/defaylt/files/clean-water-state-revolvine-fynd-infrastryctyre-report.pdf 42. American Public Health Association (APHA). Protecting the health of children: A national snapshot of environmental health services. Washington, DC: American Public Health Association; 2019. https://www.apha.org/- /media/files/pdf/topics/environment/protecting the health of children.ashx 43. Bowen K, Krishna T, Backer L, Hodgins K, Waller LA, Gribble MO. State-level policies concerning private wells in the United States. Water Policy. 2019; 21(2):428-435. https://doi.ore/10.2166/wp.2019.205 44. New Jersey Department of Environmental Protection (NJDEP). Air pollution investigation guidelines. Trenton, NJ: NJDEP, Compliance and Enforcement; 2007. 39 N.J.R 3999(c). https://www.ni.eov/dep/enforcement/syb 5 guidlines 39njr912.pdf 45. (EPA) EPA. Additional resources and tools related to EJScreen. U.S. Department of the Interior, Environmental Protection Agency; 2023. https://www.epa.gov/ejscreen/additional-resources-and- tools-related-ejscreen 46. Kuruppuarachchi L, Kumar A, Franchetti M. A comparison of major environmental justice screening and mapping tools. Environmental Management and Sustainable Development. 2017; 6:59. 10.5296/emsd.v6il. 10914 47. Konisky D, Gonzalez D, Leatherman K. Mapping for environmental justice: An analysis of state level tools. Environmental Resilience Institute and Indiana University, O'Neill School of Public and Environmental Affairs; 2021. https://eri.iu.edu/documents/ei-mapping-tools-report.pdf ------- Administrator Regan Page 13 February 28, 2023 48. Barkin JL, Buoli M, Curry CL, von Esenwein SA, Upadhyay S, Kearney MB, Mach K. Effects of extreme weather events on child mood and behavior. Dev Med Child Neurol. 2021; 63(7):785-790. https://doi.ore/10.llll/driicii.14856 49. Centers for Disease Control and Prevention (CDC). Risk and protective factors. Atlanta, GA: U.S. Department of Health & Human Services, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention; 2021. https://www.cdc.gov/violencepreveiitioii/aces/riskprotectivefactors.html 50. Philipsborn RP, Cowenhoven J, Bole A, Balk SJ, Bernstein A. A pediatrician's guide to climate change- informed primary care. Curr Probl Pediatr Adolesc Health Care. 2021; 51(6):101027. https://doi.ore/10.1016/j.cppeds.2021.101027 51. Romanello M, Di Napoli C, Drummond P, Green C, Kennard H, Lampard P, Scamman D, Arnell N, Ayeb- Karlsson S, Ford LB et al. The 2022 report of the Lancet Countdown on health and climate change: Health at the mercy of fossil fuels. Lancet. 2022; 400(10363):1619-1654. https://doi.ore/10.101S/s0140-S73Sf22)01540-9 52. Environmental Protection Agency (EPA). Seasonality and climate change: A review of observed evidence in the United States. Washington, DC: U.S. Department of the Interior, Environmental Protection Agency; 2021. EPA 430-R-21-002. https://www.epa.gov/climate-indicators/seasonalitv-and-climate- chanee. 53. U.S. Global Change Research Program (USGCRP). USGCRP's Indicator Platform. Washington, DC: White House Office of Science and Technology, National Science and Technology Council, Subcommittee on Global Change Research; 2018. www.globalchanee.gov/browse/indicators 54. Rich N. New data insights: Adverse childhood experiences, climate change, preparedness, and more. JPHMP Direct Blog. 2022. https://iphmpdirect.com/2022/Q7/26/new-data-insights-adverse- childhood-experiences-climate-change-preparedness-and-more/ 55. Heindel JJ, Howard S, Agay-Shay K, Arrebola JP, Audouze K, Babin PJ, Barouki R, Bansal A, Blanc E, Cave MC et al. Obesity II: Establishing causal links between chemical exposures and obesity. Biochem Pharmacol. 2022; 199:115015. https://doi.Org/10.101S/i.bcp.2022.115015 56. Kahn LG, Philippat C, Nakayama SF, Slama R, Trasande L. Endocrine-disrupting chemicals: implications for human health. The Lancet Diabetes & Endocrinology. 2020; 8(8):703-718. https://doi.org/10.1016/52213-8587(20)30129-7 57. Fudvoye J, Lopez-Rodriguez D, Franssen D, Parent AS. Endocrine disrupters and possible contribution to pubertal changes. Best Pract Res Clin Endocrinol Metab. 2019; 33(3):101300. 10.1016/j.beem.2019.101300 58. Kay JE, Cardona B, Rudel RA, Vandenberg LN, Soto AM, Christiansen S, Birnbaum LS, Fenton SE. Chemical effects on breast development, function, and cancer risk: Existing knowledge and new opportunities. Curr Environ Health Rep. 2022; 9(4):535-562.10.1007/s40572-022-00376-2 59. Maffini MV, Vandenberg LN. Failure to launch: The Endocrine Disruptor Screening Program at the U.S. Environmental Protection Agency. Front Toxicol. 2022; 4:908439. https://doi.ore/10.3389/ftox.2022.908439 60. Rodgers KM, Swartz CH, Occhialini J, Bassignani P, McCurdy M, Schaider LA. How well do product labels indicate the presence of PFAS in consumer items used by children and adolescents? Environ Sci Technol. 2022; 56(10):6294-6304. 10.1021/acs.est.lc05175 61. Environmental Protection Agency (EPA). EPA releases testing data showing PFAS contamination from fluorinated containers. U.S. Department of the Interior, Environmental Protection Agency; 2021. https://www.epa.eov/newsreleases/epa-releases-testine-data-showine-pfas-contamination- fluorinated-containers 62. Environmental Protection Agency (EPA). Per- and polyfluoroalkyl substances (PFAS) in pesticide and other packaging. U.S. Department of the Interior, Environmental Protection Agency; 2022. https://www.epa.eov/pesticides/pfas-packaeine ------- Administrator Regan Page 14 February 28, 2023 63. Consumer Reports. Dangerous PFAS chemicals are in your food packaging. 2022. https://www.consymerreports.ore/health/food-coiitaniinaiits/daneeroys-pfas-cheniicals-are-iii- vour-food-packaging-a3786252074/ 64. Lauria MZ, Nairn A, Plassmann M, Faldt J, Suhring R, Benskin JP. Widespread occurrence of non- extractable fluorine in artificial turfs from Stockholm, Sweden. Environmental Science & Technology Letters. 2022; 9(8):666-672.10.1021/acs.estlett.2c00260 65. Maine Department of Environmental Protection (DEP). PFAS in products. 2022. https://www.maine.eov/dep/sj3ills/topics/pfas/PFAS-prodycts/index.html 66. Washington State Department of Ecology. Chapter 173-337 WAC - Safter products restrictions and reporting. Washington Department of Ecology; 2023. https://ecology.wa.gov/Regulations- Permjts/Laws-rules-rujemakine/Rylemakine/WAC-173-337 67. Interstate Chemicals Clearinghouse (IC2). High priority chemicals data system (HPCDS). Washington State Department of Ecology; Oregon Health Authority; 2023. https://hpcds.theic2.org/Search 68. Colorado General Assembly. Perfluoroalkyl and polyfluoroalkyl chemicals. 2022. HB22-1345. 69. Environmental Protection Agency (EPA). EPA requires reporting on releases and other waste management for nine additional PFAS. U.S. Department of the Interior, Environmental Protection Agency; 2023. https://www.epa.gov/newsreleases/epa-regyires-reportine-releases-and-other-waste-manaeement- nine-additional- pfas#:~:text=As%20part%20of%20EPA's%20PFAS.%2C%20or%20de%20minimis%2C%20concentratio ns 70. Zheng G, Schreder E, Dempsey JC, Uding N, Chu V, Andres G, Sathyanarayana S, Salamova A. Per- and Polyfluoroalkyl Substances (PFAS) in breast milk: Concerning trends for current-use PFAS. Environ Sci Technol. 2021; 55(ll):7510-7520. https://doi.org/10.1021/acs.est.0c06978 71. LaKind JS, Verner MA, Rogers RD, Goeden H, Naiman DQ, Marchitti SA, Lehmann GM, Hines EP, Fenton SE. Current breast milk PFAS levels in the United States and Canada: After all this time, why don't we know more? Environ Health Perspect. 2022; 130(2):025002. https://doi.org/10.1289/EHP10359 72. Appel M, Forsthuber M, Ramos R, Widhalm R, Granitzer S, Uhl M, Hengstschlager M, Stamm T, Gundacker C. The transplacental transfer efficiency of per- and polyfluoroalkyl substances (PFAS): A first meta- analysis. J Toxicol Environ Health. 2022; 25(l):23-42. https://doi.org/10.108Q/10937404.2021.2QQ9946 73. Haervig KK, Petersen KU, Hougaard KS, Lindh C, Ramlau-Hansen CH, Toft G, Giwercman A, H0yer BB, Flachs EM, Bonde JP et al. Maternal exposure to per- and polyfluoroalkyl substances (PFAS) and male reproductive function in young adulthood: Combined exposure to seven PFAS. Environ Health Perspect. 2022; 130(10):107001. https://doi.org/10.1289/EHP10285 74. Rickard BP, Rizvi I, Fenton SE. Per- and poly-fluoroalkyl substances (PFAS) and female reproductive outcomes: PFAS elimination, endocrine-mediated effects, and disease. Toxicology. 2022; 465:153031. https://doi.Org/10.1016/i.tox.2021.153031 75. Carwile JL, Seshasayee SM, Aris IM, Rifas-Shiman SL, Claus Henn B, Calafat AM, Sagiv SK, Oken E, Fleisch AF. Prospective associations of mid-childhood plasma per- and polyfluoroalkyl substances and pubertal timing. Environ Int. 2021; 156:106729. https://doi.Org/10.1016/i.envint.2021.106729 76. Ernst A, Brix N, Lauridsen LLB, Olsen J, Parner ET, Liew Z, Olsen LH, Ramlau-Hansen CH. Exposure to perfluoroalkyl substances during fetal life and pubertal development in boys and girls from the Danish National Birth Cohort. Environ Health Perspect. 2019; 127(1):17004. https://doi.ore/10.1289/ehp3567 77. H0jsager FD, Andersen M, Juul A, Nielsen F, Moller S, Christensen HT, Gr0ntved A, Grandjean P, Jensen TK. Prenatal and early postnatal exposure to perfluoroalkyl substances and bone mineral content and density in the Odense child cohort. Environ Int. 2022; 167:107417. https://doi.ore/10.1016/i.envint.2022.107417 ------- Administrator Regan Page 15 February 28, 2023 78. Lee JE, Choi K. Perfluoroalkyl substances exposure and thyroid hormones in humans: Epidemiological observations and implications. Ann Pediatr Endocrinol Metab. 2017; 22(1):6-14. https://doi.Org/10.6065/apem.2017.22.l.6 79. Geiger SD, Yao P, Vaughn MG, Qian Z. PFAS exposure and overweight/obesity among children in a nationally representative sample. Chemosphere. 2021; 268:128852. https://doi. org/10.1016/i.chemosphere.2020.128852 80. National Academies of Sciences Engineering and Medicine (NASEM). Guidance on PFAS exposure, testing, and clinical follow-up. Washington, DC: The National Academies Press; 2022. https://doi.org/10.17226/26156 81. Graber JM, Alexander C, Laumbach RJ, Black K, Strickland PO, Georgopoulos PG, Marshall EG, Shendell DG, Alderson D, Mi Z et al. Per and polyfluoroalkyl substances (PFAS) blood levels after contamination of a community water supply and comparison with 2013-2014 NHANES. J Expo Sci Environ Epidemiol. 2019; 29(2):172-182. https://doi.org/10.1038/s41370-018-0Q96-z 82. Government Accountability Office (GAO). Persistent chemicals: EPA should use new data to analyze the demographics of communities with PFAS in their drinking water. Washington, DC: United States Government Accountability Office, Report to Congressional Requesters; 2022. GAO-22-105135. https://www.gao.gov/assets/gao-22-105135.pdf ------- Administrator Regan Page A-l February 28, 2023 Appendix A Charge Questions to the Children's Health Protection Advisory Committee (CHPAC) Regarding America's Children and the Environment August 2022 Background America's Children and the Environment (ACE) brings together information from a variety of sources to report on trends and key indicators related to children's environmental health. The main purposes of ACE are to: Compile data from a variety of national sources to present concrete, quantifiable indicators for key factors relevant to the environment and children's health in the United States, Inform discussions among policymakers and the public about how to improve data on children's environmental health, and Help policymakers and the public track trends in children's environmental health and ultimately help identify and evaluate ways to minimize environmental impacts on children. ACE indicators allow EPA to reach a broad audience with important information on trends in children's environmental health that highlight successes and identify areas that warrant additional attention, potential issues of concern, and persistent problems. EPA hopes new and updated indicators will motivate continuing research, additional data collection, and necessary interventions, when appropriate. EPA has published ACE for over 20 years. Over time, EPA has updated and improved its content, including making the data more understandable and accessible. As data and resources have allowed, EPA has added data sources, modified indicators, and stratified the data (e.g., race, income). Previously, CHPAC commented on ACE in several letters (see Appendix 1) and EPA responded by implementing most recommendations. In May 2022, EPA transitioned ACE to a dynamic digital format with downloadable data and graphics for many of the indicators. This latest update was presented to the CHPAC at its Spring 2022 plenary meeting followed by a review of the purpose and audience for this information, as well as a discussion of potential opportunities for improvements to and expansion of the indicators and website. The intended target audiences, as well as the interpretation and use of the data, were of interest to the CHPAC. To ensure ACE's ongoing relevance and influence in the children's environmental health field, EPA wishes to build on the Spring 2022 plenary meeting discussion by obtaining advice from CHPAC on the future direction of ACE. Under this charge, EPA requests CHPAC's feedback on a set of questions in three categories: content, visualization, and outreach. Charge Questions Question 1 (Content) EPA strives to ensure that ACE remains a relevant tool by adding and updating data sources, topics, and indicators as data become available and resources allow. a) What additional data sources could ACE incorporate to enhance existing indicators? b) To date, EPA has selected indicators for inclusion that are national in scope, use population- based data, portray a data series over time, and contain demographic characteristics for stratification (see Appendix 2). Using these criteria, are there indicators missing from ACE that ------- Administrator Regan Page A-2 February 28, 2023 EPA could develop? If so, what are they and their data sources? Please suggest the relative priority among the indicators identified. c) Supplementary Topics Measures (see Appendix 3) cover additional topics for which adequate national data are not available. Data sets used for these measures are representative of particular locations (such as a single state) and/or are surveys conducted a single time rather than on a continuing or periodic basis. Using these criteria, are there measures missing from ACE that EPA could develop? If so, what are they and their data sources? Please suggest the relative priority among the measures identified. d) Which data sources, topics, indicators, or measures currently included in ACE, if any, should be retired? Question 2 (Visualization) EPA intends to better use the capabilities provided by digital platforms to improve how ACE data are presented,accessed, and used. a) What digital visualization or analytic features could be included in future iterations of ACE? When possible, please provide examples to illustrate the recommendation(s). Question 3 (Outreach) EPA wishes to enhance outreach on ACE to ensure that audiences such as policymakers at different levels of government and the public are made aware of the data and information and learn of future updates. a) Who should EPA prioritize for outreach to increase awareness and use of ACE? b) What would be the most effective means to publicize and disseminate ACE findings? ------- Administrator Regan Page B-l February 28, 2023 Appendix B CHPAC's specific recommendations in response to EPA's ACE charge questions Broad recommendations for future updates and expansions of ACE: 1. ACE should distinguish itself from efforts of other data platforms and indicator reports by drawing explicit attention to, and contextualizing, children's environmental health issues; and, 2. ACE should receive additional resources, including funding and dedicated full-time employees with appropriate skill sets, to ensure that it reflects the current state of the science on children's environmental health and that data visualization and outreach strategies are properly implemented to maximize the report's utility and impact. Question 1 -ACE Indicator Selection: 1. EPA should develop an expanded core set of indicators that represents a balanced portfolio of indicator types. Indicators and measures should be reviewed and updated on a routine basis using an iterative and inclusive process. 2. "Special issues" of the ACE report should be developed to supplement the core set of indicators and provide valuable information on specific topic areas. These special issues are a mechanism to deliver time-sensitive information about high-priority and/or emerging threats to children's health and to highlight gaps in understanding of children's exposures, health outcomes, and effective ways to address behavioral, structural, or systemic challenges facing children. 3. Indicators should be amenable to policy, environmental, and systems interventions at the local, state, tribal, and/or national levels; and, 4. Content accompanying indicators should provide context on contributing factors and ways environmental impacts on children can be minimized (e.g., success stories). Additional content to orient the reader to other available information and data tools related to the indicator topic is also suggested. Question 2-ACE Visualization and Analytic Features: 1. Rather than one overarching visualization approach, the report should offer a range of visualization framework options that users can select to fit their own purpose. ACE should also include simple visualizations with associated content to highlight core findings and messages. 2. Indicator presentation should be designed to help organizations and communities contextualize key messages in ACE and focus their resources and efforts to improve the health and well-being of children. 3. Where possible, EPA should use visualizations to integrate data and measures in order to highlight relationships and increase actionability. 4. EPA should engage experts in analytical methods, data informatics, visualization techniques, communication, user experience, and community engagement to support and strengthen the visualization program for ACE; and, 5. EPA should obtain feedback from difference audiences (e.g., advocacy and community groups) on the usefulness of the information and modes of presentation. Question 3 -ACE Outreach and Dissemination: 1. EPA dedicate more resources to ACE as an important outreach product and communication opportunity that requires investment in audience engagement and communication strategies. ------- Administrator Regan Page B-2 February 28, 2023 2. ACE should actively engage with key audiences, such as PEHSUs and community and advocacy groups, using bidirectional communication starting early in the indicator selection process; and, 3. The scientific community and those in decision-making roles in government and private enterprise are important audiences to target for outreach efforts, as they are well positioned to address knowledge gaps and act upon ACE findings. ------- Administrator Regan Page C-l February 28, 2023 Appendix C Comparisons of Children's Environmental Health Tracking Tools0 Comparison of EPA's America's Children and the Environment and the Report on the Environment The EPA's America's Children and the Environmental (ACE) is a central repository to track and evaluate national level children's environmental, biomonitoring and health data. The ACE Report contains 36 indicators with the goal of understanding the impacts environmental hazards have on children and educate the public and policymakers on trends. o A core set of ACE indicators are also used for the America's Children Report including - asthma, blood lead data, blood cotinine, NAAQS, and drinking water violations. The EPA Report on the Environment (ROE) contains environmental (air, water, land, and ecological), biomonitoring and health data. The ROE contains 80 indicators that measure how the condition of the U.S. environment and human health is changing over time. While there is considerable overlap with ACE and ROE, there are some key differences. o Overall unique features of ACE ¦ ACE includes a trend analysis, while ROE does not. ¦ Several of the ACE biomonitoring indicators include a breakout for women of childbearing age. ¦ ACE includes income status for some health and biomonitoring indicators not part of ROE. o Unique aspects within the ACE Environmental indicators ¦ NAAQS data - ACE describes percent of children living in counties with levels above the standard. In contrast, the ROE displays concentrations overtime and by region. ¦ Superfund/RCRA sites - ACE shows proximity of children to corrective action sites with income, race and ethnicity. The ROE has the status by number over time of corrective action sites. ¦ Drinking water violations - ACE presents percent of children served by water systems with violations. ROE displays percent of U.S. population served. o Unique aspects within the ACE Health indicators ¦ ACE tracks neurodevelopmental (ADHD, autism and learning disabilities) and childhood obesity, while ROE does not. ¦ The ACE asthma indicator includes income status. Both include age and race/ethnicity. o Unique aspects within the ACE Biomonitoring indicators ¦ Biomonitoring data for PFAS, perchlorate, and PBDEs not in currently in the ROE. ¦ ACE shows women of child-bearing age breakouts for cotinine, PCBs, PFAS, perchlorate, and phthalates. c The CHPAC thanks Amelia Nguyen, CHPAC Designated Federal Official, for compiling this information. ------- Administrator Regan Page C-2 February 28, 2023 ¦ Income level breakouts included in the ACE biomonitoring, that are not part of ROE. Comparison of these reports by indicator topic is shown in Table C-l. Table C-l. Indicators within ROE, ACE, and the America's Children Report Report on the Environment* America's Children and The Environment** America's Children Report*** Environment Indicators Air Toxics Concentrations X X Drinking Water X X X NAAQS X X X Pesticide Incidents X Pesticide Residues in Food X X Radon: Homes > EPA's Action Level X Indoor Lead Dust - HUD (2006 was the last data set) X Contaminated Land/Waste X X Health Indicators Asthma X X X Birth Defects X X Infant Mortality X Low Birthweight X X Preterm Delivery X X Childhood Cancer X X Infectious Disease associated with Envi. Exposures! X Neurodevelopmental X Childhood obesity X Biomonitoring Indicators Blood Cadmium X Blood Lead X X X Mercury X X Cotinine X X X PFAS X Serum Pesticides (last data set 2004) X Urinary Pesticides (last data set in 2004 and 2008) X Urinary Phthalates X X Perchlorate X ------- Administrator Regan Page C-3 February 28, 2023 Report on the Environment* America's Children and The Environment** America's Children Report*** PCBs X X PBDEs X Green highlight marks indicator unique to ACE * ROE has additional indicators, but only indicators related to CEH are listed in the table. ** ACE, when available, includes women of childbearing age and income and a trend analysis of the data. *** The specified indicators from the America's Children Report use ACE indicators data submitted by OCHP. ilncludes Cholera, Typhoid Fever, Hep. A, Cryptosporidiosis, Shigellosis, Giardiasis, Salmonellosis, STEC, Lyme disease, Spotted fever rickettsiosis, West Nile, and legionellosis EJ Screen EPA EJ Screen is a mapping and screening tool, combining environmental and demographic indicators. EJ Screen users choose a geographic area; the tool then provides demographic and environmental information for that area. The 6 demographic indicators: o Percent Low-Income* o Percent People of Color* o Less than high school education o Linguistic isolation o Individuals under age 5* o Individuals over age 64 The 11 EJ indexes: o National Scale Air Toxics Assessment Air Toxics Cancer Risk* o National Scale Air Toxics Assessment Respiratory Hazard Index o National Scale Air Toxics Assessment Diesel PM (DPM) o Particulate Matter (PM2.5)* o Ozone* o Lead Paint Indicator o Traffic Proximity and Volume o Proximity to Risk Management Plan Sites o Proximity to Treatment Storage and Disposal Facilities o Proximity to National Priorities List Sites* o Wastewater Discharge Indicator * Data included in the ACE Report CDC's Environmental Public Health Tracking CDC's Environmental Public Health Tracking (EPHT) - combines health and environment data from national, state, and city sources. The CDC's EPHT has data and information on: ------- Administrator Regan Page C-4 February 28, 2023 ° Environments and hazards - Climate change, community characteristics, drinking water, drought, outdoor air, pesticide exposures, radon testing, sunlight and UV, and toxic releases. o Health effects - Asthma, birth defects, cancer, carbon monoxide poisoning, childhood blood lead, COPD, heart disease, heat stress, developmental disorders, birth outcomes and hormone disorders. ° Population health (also included in CDC's EJ content) - Demographics, socioeconomic status, health status (such as such as number/ percent of people over 5 years of age with a disability in a Census track/county), life expectancy at birth, and Social Vulnerability Index (relative vulnerability by Census tract on 14 social factors including poverty, lack of vehicle access, and crowded housing. Each Census tract receives a ranking for each variable and theme. Data can be used local health officials to for preparedness). Other features of the CDC's EHPT ° Data Explorer to view interactive maps, tables, and charts and Info by Location o Heat and Health Tracker ¦ Data on heat-related emergency room visits and hospitalizations (based on ICD- 10 data) could be a climate change indicator for ACE. ¦ Heat Adaption Story Map - an ORISE project and good reference for any future ACE Story Maps. CEHN Children's Health Indicators Report CEHN's 2018 Children's Environmental Health Indicator Summary and Assessment Report provides an overview of the available children's health indicators ACE Report - quotes from interviewees: o ACE Report is the most extensive national effort focused specifically on indicators related to children's health and the environment, o The only effort specific to children's environmental health is the EPA's ACE. ACE is especially helpful in identifying national-level trends and issues and policy implications o The ACE children's indicators serve as the basis for a national conversation about children's environmental health. A significant concern is the uncertainty of its future and the ability of the EPA to continue to update data and provide subsequent editions. America's Children Report - effort involves 23 federal agencies and includes 41 indicators associated with the health of children. EPA supplies five indicators. EPA ROE - Several indicators are specific to children's environmental health (e.g., blood lead levels and childhood cancers) with several indicators/data align with ACE. EJ Screen -11 environmental and six demographic indicators, combined to create EJ indexes. CDC's Environmental Public Health Tracking Network is a multi-tiered web-based surveillance system that combines environmental exposure, hazard and health outcome data into one platform WHO 2003 Children's Environmental Health: A Call for Action -The goal to increase the use of indicators, improve ways to monitor children's health and promote policies that benefit children's health. ------- Administrator Regan Page C-5 February 28, 2023 The 2006 Children's Health and the Environment in North America outlines 13 children's health indicators in three categories: asthma and respiratory disease, lead and other chemical exposures, and waterborne diseases. The report references the ACE Report several times. Healthy People 2020 Report - Of note the Healthy People 2030 goals are out. o Several ACE indicators align with Healthy People 2020 and 2030 objectives including air quality, air toxics, drinking water, blood lead, cotinine, mercury, lead paint, PCBs, platelets, BPA, perchlorate, asthma, childhood cancer, birth outcomes, obesity... o Healthy People tracks three birth defects - neural tube defects, spina bifida and anencephaly o Healthy People 2030 has a new goal to Increase the proportion of schools with policies and practices that promote health and safety EH-D01 (no data provided yet). The County Health Rankings and Roadmaps - ranks the health of communities by health outcomes and factors, including length of life (premature death), quality of life (low birth weight), health behaviors, clinical care, social and economic factors, and physical environment. Health Schools Network Towards Healthy Schools: Reducing Risks to Children (2016) - assesses state-by-state environmental health hazards at schools and the data needed to evaluate impact on children's health. This report includes 15 specific issues 15: asthma, fracking, and well water; federal poverty statistics (e.g., the number of children in a school eligible for free/reduced meals). American Lung Association's State of The Air Report - ranks states and cities by air quality and provides information on groups at risk in the area (e.g., number of pediatric asthma cases or cases among children under 18). ------- Administrator Regan Page D-l February 28, 2023 Appendix D Indicator topics to consider for future iterations of ACE To include the most up-to-date information and better coverage of the landscape of environmental health issues facing children, CHPAC compiled a non-exhaustive list of indicator topic recommendations for EPA to consider adding to future ACE reports (Table D-l). It is intended to provide EPA with enough specificity to outline where gaps exist and where additional information could provide a more complete picture of any one topic within ACE. This list does not reflect all children's environmental health topics of importance. Additional information on approaches and expansions of select topics is found in the discussion following this table. Indicators in future ACE reports should be considered under the proposed, inclusive selection process outlined in the response to Charge Question 1. Table D-l. Non-exhaustive list of suggested indicator topics not currently included in ACE Children's Environmental Health Topics Example Indicator Topics Notes Home Environments Housing characteristics Chemicals in house dust Inventory and replacement of lead service lines (LSL) American Healthy Homes Survey data may be a useful data source for housing characteristics. Some chemicals commonly found in dust include lead, PFAS, flame retardants, phthalates, and bisphenols. Completed inventories and LSL replacement under revised Lead and Copper rule could serve as solution indicators. Learning Environments Clean school buses Chemical contaminants Children living in areas with/without state or local requirements for lead and radon testing and mitigation in schools and child care facilities Heating, ventilation, and air conditioning (HVAC)/air filtration improvement and indoor air quality in schools and child care facilities Number of buses converted to electric or low-emission fuel sources and percent of children in schools/child care that have state/local requirements to test for/abate lead and radon are examples of "solutions" indicators. Chemical contamination source examples: cleaning and art products, nap mats, lead paint, 3D-printers, science labs, construction products (e.g., containing PCBs). Air Pollutants Wildfire smoke-related air quality Emerging pollutants Pollutant levels and air quality standard exceedances specific to wildfire smoke. Example emerging pollutants include ethylene oxide, ultrafine particulate matter. ------- Administrator Regan Page D-2 February 28, 2023 Children's Environmental Health Topics Example Indicator Topics Notes Indoor air quality (i.e., specific characteristics associated with poor air quality such as gas stoves, maintenance defects, etc.) Children living in areas with higher lead concentrations due to aviation gas (avgas) Chemicals in Commercial and Harvested foods Pesticides in food commonly consumed by children Food-related contamination sources Toxic metals Mercury, PFAS, and other contaminants in fish Food-related contaminant sources include food packaging, applied biosolids, contaminated soils. Metals (e.g., arsenic, lead, cadmium) in foods commonly consumed by children, including infant formula and the water used to reconstitute it. Contaminated Sites Clean-up sites School and child care locations Expand existing contaminated sites indicator in current ACE by examining sites on state clean up lists. o State and local tracking information may be useful data sources, o Example contaminated sites: abandoned gas stations, dry cleaners. Consider linking contaminated sites indicators with other indicators in ACE related to contamination and chemical pollution to characterize cumulative impacts. Number of children impacted by contaminated sites. School and child care proximity to contaminated sites. Chemical and Non- chemical Pollution Pesticides Additional metals Endocrine disrupting chemicals (EDCs) (recommended as a Special Issue in Appendix E) PFAS (recommended as a Special Issue in Appendix E) Radio Frequency Radiation (RFR) Emerging and existing hazards and exposures should be considered for chemical pollutants: o Example metals: arsenic, chromium, manganese, o Example EDCs: bisphenols other than bisphenol A (BPA), phthalates, mixtures. Consider results from total fluorine analytical methods for PFAS in addition to individual analytes. Consider linking EDCs indicators with the existing obesity indicator in ACE. Explore chemicals shown to impact mammary gland and normal reproductive development. Assess Toxic Release Inventory (TRI) data. ------- Administrator Regan Page D-3 February 28, 2023 Children's Environmental Health Topics Example Indicator Topics Notes Project TENDR may be a useful source to identify chemical pollutants that impact neurodevelopment.31 Chemicals in Consumer and Personal Care Products Chemicals in consumer and personal care products commonly used by children Chemicals in consumer products known to migrate/leach to indoor air/dust Chemicals in children's products Consumer Products Safety Commission (CPSC) and FDA data may be good sources. While many consumer and personal care products are not regulated by EPA, they must be factored into children's total exposure to chemicals that cross regulatory jurisdications. State lists and manufacturing reports identify chemicals in children's products. Lack of information on chemicals in products could be highlighted by ACE as a gap. Example chemicals in consumer/personal care products include lead, PFAS, flame retardants, phthalates, bisphenols, parabens, antimicrobial pesticides. Drinking Water Contaminants Regulated and unregulated contaminants, including nitrate and PFAS Private wells Since there are many sources and types of PFAS, we recommend a special issue of ACE on this topic. See Appendix E. UCMR monitoring data and state monitoring programs may be useful data sources for unregulated contaminants. While private wells are not regulated by EPA, they represent a major source of drinking water for children and families and should be included in ACE. Groundwater data can serve as a proxy; United States Geological Survey (USGS) is a good data source. Internal Exposure to Environmental Chemicals Chemicals with higher exposures among children compared to adults Chemicals for which children have greater biologic vulnerability or that are associated with adverse reproductive and birth outcomes Chemicals known to pass through to the fetus or to breastmilk NHANES biomonitoring data continues to be a useful source. Also consider state biomonitoring program data. Consider biomonitoring data within certain subpopulations (e.g., farmworker children), which could serve as useful data stories. Biomonitoring data from other countries may be useful where data from the United States are lacking. Biomonitoring data should focus on chemicals in current use. Biomarker and biomatrix selection should be carefully considered to capture actual exposures (e.g., measure degradate of a pesticide rather than parent compound that is quickly transformed) ------- Administrator Regan Page D-4 February 28, 2023 Children's Environmental Health Topics Example Indicator Topics Notes The Human Health Exposure Analysis Resource (HHEAR) could provide expert consultation.32 Neurodevelopmental Disorders Autism indicator expansion ADD/ADHD Learning and intellectual disabilities Vision and hearing impairments Expand existing autism indicators in current ACE with sub-indicators specifying severity and presence of accompanying impairments.33 Expand existing ADD/ADHD and learning disability indicators in current ACE to include data beyond the CDC's National Center for Health Statistics (NCHS) National Health Interview Survey data to include, for example, epidemiological data, relevant ICD-10 coding, and coding tracked through the Individuals with Disabilities Education Act (IDEA) Part B to distinguish type of disability. This would expand tracking to additional neurodevelopmental disabilities. Respiratory Outcomes Wildfire smoke-related illnesses Wood smoke-related illnesses Vaping-related illnesses and disease School absences from wildfire smoke and asthma/respiratory illnesses See Air Pollutants topic above for example pollution indicators. CDC could serve as a helpful source for data on e-cigarette, or vaping, product use-associated lung injury (EVALI) among children and adolescents. Wildfire smoke-related example indicators are also suggested for a climate change special issue in Table E-l. Metabolic Outcomes Diabetes Large for gestational age (LGA) births Link existing obesity indicator with chemical exposures (e.g., EDCs - see Chemical Pollutants topic above) and diet data. Developmental Abnormalities Precocious puberty Hypospadias Cryptorchidism Reproductive development Data on thelarche and menarche could serve as useful measures of precocious puberty. Childhood Cancer Childhood cancer indicator expansion Expand existing childhood cancer indicator with additional cancer types, such as testicular cancer, and linkages to other indicators. Reproductive and Birth Outcomes Hypertensive disorders of pregnancy Stillbirth Gestational diabetes Severe maternal morbidity Analyze exposures known to impact health in pregnancy, such as air pollution, EDCs, and extreme heat and their relationship to maternal and child health outcomes. This indicator topic is discussed further below. ------- Administrator Regan Page D-5 February 28, 2023 Children's Environmental Health Topics Example Indicator Topics Notes Other Health Outcomes Pesticide illness and injury among children Immune system effects among children Children diagnosed with vector-borne diseases Vector-borne diseases are also suggested as an example indicator for a climate change special issue in Table E-l. Poison control center databases and medical/emergency room visits may be good data sources to track for pesticide illness and injury. Cumulative Impacts and Environmental Justice* Highly impacted neighborhoods Equitable allocation of EPA grants and assistance allocated to children's environmental health Schools with high poverty levels identified through Title 1 data. Number of children who live in overburdened communities. Crosswalk with data from EJScreen, CDC's Social Vulnerability Index (SVI), CDC's Environmental Justice Index, etc. This indicator topic is discussed further below. State and local services and regulations that impact children Elevated blood lead home visits Requirements for water quality testing of private wells Lead inspection requirements (e.g., for rental housing) Window replacement grants for lead Childcare safe siting programs These indicators could be developed for each state and territory. This indicator topic is discussed further below. Climate Change See Appendix E for a table with example climate change indicators Since there are many potential indicators to assess climate change and its impact on children, we recommend a special issue of ACE on this topic in Table E-l. Federal investments in Children's Environmental Health Indicators that measure and track funding for children's environmental health Research funding (e.g., Project ECHO) Children's Environmental Health Centers CEH grants allocated *EPA should confer with NEJAC on additional vulnerabilities that should be considered for all Environmental Health topics considered for ACE. ------- Administrator Regan Page D-6 February 28, 2023 Examples of ways to expand or include indicators listed in Table D-l in ACE 1. Reproductive and Birth Outcomes Pregnancy constitutes a window of vulnerability for both the fetus and the pregnant person.34 The ACE report should build on previous indicators to address this window directly to be fully inclusive of the life course continuum of potential adverse exposures and outcomes. Exposures that impact children's health (including air pollution, toxics, high heat) can also impact pregnancy, potentially increasing complications such as preterm birth or preeclampsia.35,36 These pregnancy complications can have major implications for the fetus and throughout the child's lifespan. For example, lead is a toxicant that has well-established impacts on neurodevelopment and is also associated with other adverse health outcomes, such as hypertension, including hypertensive disorders of pregnancy.37"39 Adding additional pregnancy-related indicators to ACE, such as hypertensive disorders of pregnancy, gestational diabetes, and severe maternal morbidity (and mortality) will highlight opportunities to protect children's health within the context of the complete life course and the family. Additionally, women of childbearing age or pregnant people should be considered as subpopulations of interest for hazard indicators included in ACE; for example, in addition to the percent of children living near contaminated sites, the percent of women of childbearing age living near these sites could also be identified. 2. Cumulative Impacts New and ongoing indicators included in ACE should emphasize impacts on children with the greatest burden of cumulative exposures. Exposures associated with economic and political conditions increase child vulnerability, and associated risks are magnified for low-income, refugee, and immigrant populations, as well as for communities of color. The precautionary principle in environmental health should guide this endeavor, with the underlying presumption that reducing exposures will protect children's health.40 All available information should be used to assess populations impacted by cumulative exposures, including environmental justice mapping tools (national and local) and other available data (e.g., syndromic surveillance data, poison center data, data in the scientific literature, climate impacts data, and social vulnerability indicators). ACE should group indicators to highlight factors that worsen the associated health impacts for children. Additionally, ACE should identify actions that address and/or remove factors that worsen exposure-related impacts. Including cumulative exposures in ACE would enable EPA to provide risk assessors, policymakers, medical providers, public health officials, and the public at large with information about children with both increased biologic sensitivity and increased exposure risk. These populations also tend to have fewer resources at their disposal to contend with the compounded impacts of such exposures. Two examples of how such an approach could be applied are highlighted below. Cumulative impacts from air emissions are generally not regulated. If a given facility operates under their individual permit limit, there is no limitation on the number of such facilities within an impact radius. Environmental justice communities are most likely to have a disproportionate number of potentially harmful air emissions in proximity because of the lower property values and the communities' reduced capacities to organize against such facilities. An indicator that could measure air polluting facilities in aggregate within a geographic region with environmental justice populations could help identify vulnerable communities and facilitate subsequent action to protect impacted children. ------- Administrator Regan Page D-7 February 28, 2023 As an additional example, research has indicated that smaller, lower income communities with large communities of color are less likely than larger lower income communities to receive funding through the Clean Water State Revolving Fund (CWSRF) for water infrastructure improvements.41 This is likely due to lack of resources to design improvement projects or participate in the rigorous application process to obtain funding for the improvements. As a result, children in these smaller, lower income communities are more likely to be exposed to lower quality drinking water while being disproportionately subject to other health risks. Indicators that factor sociodemographic data (density of children, race/ethnicity, socioeconomic vulnerability) into measurements of the allocation of EPA funding would be useful to ensure equitable distribution of such funding. 3. State and Local Services and Regulations There is no uniform, nationwide method to deliver governmental environmental health services to residents of the U.S. and its territories. Environmental health regulations also differ across state, territory, and local levels. Therefore, we recommend that EPA develop indicators that pertain to the availability of child-focused environmental health services (e.g., home visits for children with elevated blood lead levels) and regulations (e.g., requirements for water quality testing of private wells) within each state and territory to identify gaps in regulations and service delivery to protect children. As a starting point for indicator development, useful sources of information on state and local-level environmental services can be found on the National Environmental Health Association (NEHA), National Association of County and City Health Officials (NACCHO), and American Public Health Association (APHA) websites and in reports produced by these organizations,42 as well as the literature.43 State-level environmental health services and regulation indicators are particularly amenable to linkage with health outcome indicators. For example, visualizations could relate availability of environmental services (e.g., free or low-cost window replacement programs for lead) and presence or absence of regulations (e.g., required lead inspections in rental housing) to exposure indicators (e.g., blood lead levels). Developing indexes, i.e., combinations of environmental health services or regulations or cumulative scores, would also be useful for identifying priority areas of the country and the need for data-driven actions. Using Local Data to Expand ACE's Supplemental Topics Section and Inform a National Approach While ACE generally tracks indicators at a national level, local data can be an important part of that tracking. Many states and local jurisdictions have local data, indicators, or environmental justice maps that may further contribute to information that ACE is tracking on a national scale. CHPAC recommends that ACE expand upon its current supplemental topics that represent local-level indicators. Local-level information provides a better understanding of environmental health risk and burden in locations with greater exposures and cumulative impacts. Local data can also help EPA forecast emerging national trends, identify data gaps at the national level, discern local solutions that highlight known ways to reduce exposures, and provide situational awareness to prevent harmful exposures. For example, changes in climate have led to pest migration that could facilitate more use of pest products (e.g., pesticides) in areas with historically low use. Tracking use of these products could predict locations where similar trends may occur, thus preventing exposure impacts. ------- Administrator Regan Page D-8 February 28, 2023 As another example, odor or emission violations in New Jersey are issued following a report to a State Department of Environmental Protection official and verification of the report.44 The number of reports at the state level could indicate areas where children are vulnerable to these emissions and illuminate regulatory gaps to be closed in order to be more protective of vulnerable communities. While ACE has a national focus, it is recommended that ACE staff conduct periodic screening of local tracking networks and environmental justice mapping tools as a way of identifying supplemental topics and/or data stories that illustrate the importance of assessing the state of children's environmental health at both local and national scales. EPA's EJScreen provides tools and data that can be used to examine local issues.45 EPA should also review existing analyses of methodologies to include local data in ACE; for example, many authors have examined national and state environmental justice mapping tools and assessed differences in methodologies and indicators.46,47 ------- Administrator Regan Page E-l February 28, 2023 Appendix E Indicator Topics Recommended as Special Issues of ACE Certain children's environmental health topics require elevated attention and/or are too wide-ranging and robust to be limited to a few core indicators. We provide a few examples of such topics which merit consideration as special issues of ACE. 1. Climate Change Climate change represents a multifaceted risk to children with diverse current and future projected impacts such as changes in infectious disease prevalence and distribution and asthma exacerbations. The disruption of daily routines from extreme weather events or wildfires has far reaching downstream effects on such things as learning and mental health. 48 Although interest in the health impacts of climate change is growing on federal, state, and local levels, and research documents children's unique vulnerability to climate change and related disasters, there remains a paucity of summative reports clarifying the current state of children's vulnerability in America and their resilience to climate change. Environmental hazards, internal exposures, health outcomes, vulnerabilities, and solutions are each important lenses through which to elucidate the impact of climate change on children's health (Table E- 1). Some data are already tracked by EPA or other federal and state agencies (including weather and disaster data), but how hazards, exposures, and vulnerabilities translate into health outcomes among children is an important function of ACE. For example, adult members of a family evacuated from their locality due to a climate-change magnified hurricane may suffer stress, disruption of employment or planned medical care, but a child will have their schooling disrupted, may have direct health impacts such as infection, malnutrition, or pulmonary disease, and additionally may experience what is termed an "Adverse Childhood Experience" (also commonly abbreviated ACE). ACEs have been linked with lifelong adverse health outcomes, including problems with child brain development, the immune system, and stress-response systems, as well as negative financial consequences. These events in childhood are more common in populations experiencing unstable housing and food insecurity and in times of economic stress or social isolation.49 Also important for inclusion in a special report on climate change and children's health are indicators of resilience and/or adaptation (i.e., solutions). For example, EPA is currently supporting the largest school bus electrification initiative in history. This child-specific program not only affects near-term air quality but also brings mobile battery capacity into communities for use as a component of disaster preparedness. Additional resilience indicators could be explored that represent climate change preparedness with concurrent health benefits such as green space in cities which can both lower temperatures and foster active play.50 A special report focused on a broad topic like climate change through a children's health lens could highlight innovative ways that climate health risks and solutions are interrelated. In so doing, this effort could support ACE's role as an agenda-setter. Multiple entities are working on climate change indicators51"54, which could serve as a starting point for selecting child- focused climate change indicators. Table E-l provides a non-exhaustive list of indicator topic recommendations for inclusion in a Climate Change Special Issue of ACE. Indicators were selected based on the potential to impact vulnerable populations, such as children and pregnant people. Future indicators should not be limited to those listed below. ------- Administrator Regan Page E-2 February 28, 2023 Table E-l. Example Indicators for a Climate Change Special Topics Issue Climate Change Indicator Type Example Indicator Topics Notes Environmental Hazards Temperature Relative humidity (RH) Precipitation/flooding Wildfire smoke Disaster-related pollution Allergens Climate change-related disasters Vector ranges Saltwater incursion of water supply Mean, minimum, and maximum temperature and RH; number of days with temperature above the 95th percentile. Rainfall, flooding, or other weather measures. Examples of disasters include wildfires and associated air quality, flooding, hurricanes, and tornadoes. Changes in vector ranges (e.g., Aedes mosquitoes, deer tick). These hazards can be combined with U.S. Census demographic data to quantify impacts on children. Health Outcomes Hypertensive disorders of pregnancy Mental health outcomes related to disasters Environmental allergies Vector-borne diseases Vulnerabilities Home and school locations Public transportation services Flooding Days with school closures due to elevated heat, disasters, etc. Children in homes located in Federal Emergency Management Agency (FEMA)- designated flood hazard areas. Gaps and Solutions Electric school buses School air filtration Other adaptation or intervention indicators (e.g., clean air/extreme weather shelters opened and information on their use) Coal power plant closures Solutions with co-benefits Data are not currently available on the clean school bus program. Associated indicators could include changes in air quality or electric vehicle to grid capacity Assess improvements to or supplemental air filtration in schools (e.g., HVAC upgrades and/or addition of HEPA air cleaners). Intervention or adaptation indicators may include number of clean air or extreme weather shelters and associated use information. Solutions with co-benefits include active commuting, green spaces in cities, coal power plant closures. These indicators could be considered alongside health outcome indicators (e.g., asthma, preterm birth) to assess co-benefits of climate mitigation measures. ------- Administrator Regan Page E-3 February 28, 2023 2. Endocrine disrupting chemicals (EDCs) Endocrine disrupting chemicals (EDCs) is a special ACE report topic that could hoiistically illuminate emerging information on EDC exposures, impacts on children's health, data needs, and policy gaps. EDCs interfere with the normal function of the endocrine system by mimicking hormones, disrupting normal hormonal pathways, or changing hormone levels in the blood by increasing or decreasing their production, or altering how they are degraded or stored by the body. These disruptions have been linked to altered reproduction and development, nervous and immune function abnormalities, cancers, respiratory, metabolic, and cardiovascular problems. Their links to reproduction and reproductive and neuronal development make them of particular concern to women of childbearing age and throughout pre- and peri-natal, infant, childhood and pubertal development. Because hormones regulate many important developmental periods, EDCs have the potential for serious impacts on normal development and can increase risk for diseases that manifest later in life. EDCs also have the potential to be active at very low doses and can have latent and generational impacts, so identifying and removing presumed harmful exposures could have large benefits in protecting children from adverse health outcomes throughout life. A large body of literature details their health impacts. Metabolic diseases, neurological development, and pubertal development are just a few examples of areas where the literature has identified abnormal development and links to EDCs.55"58 A special issue of ACE that focuses on EDCs can help EPA with priority setting and identifying areas where additional research and actions are needed to protect children. Consistent tracking of children's exposures, hazards, and health outcomes associated with EDCs will also further the efforts of scientists and clinicians in the endocrine field and will assist decisionmakers in developing effective approaches to regulate EDCs that are currently impacting children's health. This information could also help interested parties such as public health practitioners, communities, and parents develop strategies to reduce exposures and advocate for better environmental health policies, especially when the chemicals and health outcomes occur due to regulatory gaps.59 Furthermore, it will help identify cumulative impacts of EDCs with converging chemical exposures and other stressors. Table E-2 provides a non-exhaustive list of indicator recommendations for inclusion in an Endocrine Disrupting Chemicals Special Topics Issue of ACE. Future indicators should not be limited to those listed below. ------- Administrator Regan Page E-4 February 28, 2023 Table E-2. Example Indicators for an Endocrine Disrupting Chemicals Special Topics Issue EDC Indicator Type Example Indicator Topics Notes Environmental Hazards Pesticides EDCs in: o Children's products o Food storage containers o Electronics o Building materials o Personal care products o Antibacterial compounds o Textiles and clothing Consider utilizing testing results and prioritization schemes from EPA's Endocrine Disruptor Screening Program. Access to databases that have product usage information as well as data with compiled reporting on chemicals in products (e.g., state reporting requirements) could be useful for estimating children's exposure to these hazards through different products. Mixtures of EDCs and cumulative exposures specific for children in home and learning environments could be estimated by linking these indicators. Focus on examining chemical classes, particularly those with data on health impacts not yet addressed by regulatory activities (e.g., PFAS, benzophenones, bisphenols, phthalates, formaldehyde, trichloroethylene, benzene). Internal Exposures Chemicals in breast milk Chemicals that cross the placenta Biomonitoring (see Table D-l) NHANES and literature studies can provide data on internal exposures of pregnant women and children in different developmental stages. Health Outcomes Fertility Reproductive development Reproductive organs Early puberty Nervous system function/neurodevelopment Immune function Cancers Respiratory function Metabolism/obesity/diabetes Neurological/learning disabilities EDCs can influence metabolism, leading to maternal and childhood obesity, diabetes, and thyroid function. EDCs (e.g., bisphenols, phthalate, polychlorinated biphenyls [PCBs], dithiothreitol [DTT]) have been shown to alter reproductive health. Provide context or make linkages between health outcome indicators such as precocious puberty, mammary gland development, childhood cancers and endocrine cancers later in life and EDC hazard and exposure indicators. Include IQ deficits, ADHD, and autism in neurological/learning disabilities. ------- Administrator Regan Page E-5 February 28, 2023 Vulnerabilities Home and/or school location Age-related behaviors Age-related exposures Occupation of parents Explore exposure to environmental hazards due to home/school location and socioeconomic factors through a cumulative exposure lens. Synthesize information on sensitive life stages and health outcomes associated with EDCs, including the influence of age-specific behaviors. Explore occupations where parental exposures may lead to prenatal, breast milk, take-home, or other exposures to EDCs among children. Gaps and Solutions Removal of specific chemicals/chemical classes from products relevant to children Biomonitoring data gaps National and state regulations to remove BPA from baby bottles or phthalates from children's toys may serve as solution indicators or provide context in time trend figures. Highlight data gaps particularly for new or "replacement" EDCs. ------- Administrator Regan Page E-6 February 28, 2023 3. Per- and Polyfluoroalkyl Substances (PFAS) Currently, ACE indicators related to PFAS only include PFOS, PFOA, PFHxS, and PFNA blood serum levels measured in US women ages 16-49 from 1999-2018. Availability of PFAS-related data has increased rapidly in recent years and there is a need to integrate hazard, exposure, health outcome, and gaps and solutions indicators and cumulative exposure information to characterize environmental health impacts on children. A special ACE report on PFAS-related indicators can address this need. The extent of PFAS use in products and industrial processes is not well understood, leaving major gaps in our understanding of the extent of children's exposures to PFAS. These gaps include use in products commonly used by children and pregnant women and in household products that may leach to house dust. Current EPA analytical methods only allow for detection of a small percent of specific PFAS in a product. Large discrepancies are often seen when total organic fluorine is assessed versus methods that detect specific compounds, highlighting that there are not yet standardized analytical methods available to fully understand which PFAS are being used in products.60 In 2021, EPA identified that PFAS are unintentionally present in fluorinated HPDE plastics and is now requiring manufactures take steps to prevent the unintentional production of PFAS in plastic containers.61,62 Food contact items, artificial turf and other plastics have also been shown to contain PFAS and pose specific exposure and health risks to children.61,63; 64 To address this gap, many states are implementing reporting by manufacturers on PFAS in products sold in their states.65"68 In addition, EPA requires reporting on certain PFAS releases through the Toxic Release Inventory (TRI),69 drinking water utilities have been tested through EPA's Unregulated Contaminants Monitoring Rule (UCMR) as well as many state managed testing programs, and many utilities and jurisdictions across the country are beginning to test wastewater, biosolids, and other waste streams for PFAS, which could eventually be conducted in a manner similar to wastewater surveillance for COVID-19. ACE could track these current and emerging state and national sources of data on PFAS to develop new hazard indicators. Hazard indicators could also be tracked along with health outcome and exposure data to provide a better overall understanding of relationships between PFAS uses, exposures, and health impacts. Developing a better accounting of all PFAS exposures is important in estimating health impacts and risks to children. Additional health outcome indicators should be included in the special report, as there is a considerable body of evidence pointing to myriad health harms associated with in utero or childhood exposure to PFAS including cancers, reproductive and developmental impacts, decreased immunity, and increased cholesterol and obesity.70"79 A recent National Academies report concluded that for children, there are likely associations between chronic PFAS exposures and elevated blood cholesterol, dyslipidemias, lowered birth weight, and reduced antibody response to certain vaccines/infections.80,81 Additional health outcome indicators would allow ACE to look across trends in children's health outcomes with information on chemical production, use and exposures for PFAS. ACE can include demographic information on exposed populations to identify people who are at greater risk due to where they live or work and based on socioeconomic factors, thus prioritizing actions that reduce exposures to children of color in low income and overburdened communities. For example, a recent United States Government Accountability Office (GAO) analysis of six states with robust data looked at the relationship between PFAS occurrence and the demographics of impacted communities.82 They found clear relationships between PFAS occurrence and demographics that varied by state and community. The GAO suggested that such analyses could help EPA determine ways to ensure adequate ------- Administrator Regan Page E-7 February 28, 2023 protection from PFAS. This is a good example of where gaps exist and where ACE could pull the information for chemicals of particular concern for children's health to highlight better strategies that protect children from exacerbated harms due to specific chemicals or classes of chemicals when exposures occur along with other chemicals and stressors. A special report on PFAS that highlights the specific sensitivities, exposures, and vulnerabilities that children face could be important in developing new strategies, both regulatory- and individual- or community-focused, that can reduce children's exposures to PFAS and show measurable reductions in health impacts long term. Because PFAS is an active area of research and regulatory decision-making, a special report will also be useful in highlighting national activities and their relevance to children's health and the environments where they spend time. ------- |