vvEPA
United States EPA/600/R-24/0S2 | May 2024 | www.epa.gov/research
Environmental
Protection Agency
Evaluating Non-Chemical Stressors
for Children's Environmental
Health Protection:
Workshop Summary
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Office of Research and Development
Center for Public Health and Environmental Assessment
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FINAL REPORT
EPA 600/R-24/082 | May 2024
www.epa.gov/research
Evaluating Non-Chemical Stressors
for Children's Environmental Health
Protection: Workshop Summary
Nicolle Tulve1, Project Lead, Research Physical Scientist
Emily Eisenhauer1, Social Scientist
Jonathan Essoka2, Superfund and Technology Liaison
Intaek Hahn3, Physical Scientist
Matthew Harwell1, Supervisory Ecologist
Susan Julius1, Assistant Center Director for Sustainable and Healthy
Communities
Sarah Mazur4, Principal Associate National Program Director, Sustainable
and Healthy Communities Research Program
Michael Nye5, Risk Communication Advisor
Angie Shatas4, Associate National Program Director, Air, Climate, and
Energy Research Program
U.S. Environmental Protection Agency
Office of Research and Development
Center for Public Health and Environmental Assessment
Research Triangle Park, N.C. 27709
1 Center for Public Health and Environmental Assessment
2 Center for Enviromnental Solutions and Emergency Response
3 Office of Science Advisor, Policy, and Engagement
4 Office of Research and Development, Immediate Office of the Assistant Administrator
5 Office of Public Affairs, Office of the Administrator
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NOTICE AND DISCLAIMER
This document has been reviewed in accordance with U.S. Environmental Protection Agency,
Office of Research and Development, and approved for publication.
The appropriate citation for this report is:
Tulve N., Eisenhauer E., Essoka J., Hahn I., Harwell M., Julius S., Mazur S., Nye M., and Shatas A.
Evaluating Non-Chemical Stressors for Children's Environmental Health Protection: Workshop
Summary. U.S. Environmental Protection Agency, Research Triangle Park, NC. EPA/600/
R-24/082. 2024.
ACKNOWLEDGEMENTS
The authors thank Timothy Buckley (Office of Research and Development) and Samuel Kay
(Office of Environmental Justice and External Civil Rights) for their insightful reviews of this
report. This report is a summary of the Evaluating Non-Chemical Stressors for Children's
Environmental Health Protection workshop. Statements included in this report reflect
discussions among workshop participants and should not be interpreted as official views of the
U.S. Environmental Protection Agency.
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Table of Contents
NOTICE AND DISCLAIMER ii
ACKNOWLEDGEMENTS ii
ACRONYMS iv
EXECUTIVE SUMMARY 1
SESSION SUMMARIES 3
Keynote: Overview of EPA's Research on Non-Chemical Stressors 4
Keynote: Overview of Academic Research on Non-Chemical Stressors 4
SUBJECT-SPECIFIC PRESENTATIONS 6
Non-Chemical Stressors from the Built Environment 6
Non-Chemical Stressors from the Natural Environment 6
Non-Chemical Stressors from the Social Environment 7
Stressors and Health and Weil-Being 7
Recap of Day 1 and What Is Happening in Day 2 7
SUMMARIES OF BREAKOUTSESSIONS 8
Non-Chemical Stressors from the Built Environment 8
Non-Chemical Stressors from the Natural Environment 10
Non-Chemical Stressors from the Social Environment 12
Stressors and Health and Weil-Being 13
CLOSING REMARKS 16
KEYTAKEAWAYS FROM THE BREAKOUTSESSIONS 17
REFERENCES 19
APPENDIX A: AGENDA A-l
APPENDIX B: PARTICIPANTS B-l
APPENDIX C: PRESENTATIONS C-l
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ACRONYMS
ACE
Air, Climate and Energy National Research Program
AOP
Adverse outcome pathway
EJ
Environmental Justice
EPA
U.S. Environmental Protection Agency
HELIX
Human Early-Life Exposome Study
ORD
Office of Research and Development
PCBs
polychlorinated biphenyls
SHC
Sustainable and Healthy Communities National Research Program
StRAP4
Strategic Research Action Plans (4th round of research planning)
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EXECUTIVE SUMMARY
Children are exposed to both chemical and non-chemical stressors at each lifestage
throughout the course of their lives. Exposure to some chemical stressors (e.g., pesticides,
metals, perfluorinated compounds) is routinely measured and assessed. Research on non-
chemical stressors (e.g., poverty, violence, food insecurity, access to greenways and
recreational facilities, health care) is less routine in the context for potential combined
effects with chemical stressors. Research on the interrelationships between chemical and
non-chemical stressors and how these interactions affect health and well-being is still in its
infancy. However, animal research has shown that non-chemical stressors do affect the
biological response to chemical agents and there is every indication that this premise would
be applicable for humans. Additionally, the epidemiological literature incorporates selected
non-chemical stressors as covariates when exploring the links between chemical exposures
and health outcomes.
The U.S. Environmental Protection Agency's (U.S. EPA) Office of Research and Development
(ORD) recognized the need to develop an approach to study non-chemical stressors within a
chemical stressor paradigm. Research is needed to identify which non-chemical stressors are
likely to be most relevant, how these non-chemical stressors vary throughout the lifecourse,
and how non-chemical stressors interact with chemical stressors and with other non-
chemical stressors. Researchers in the Sustainable and Healthy Communities (SHC) National
Research Program were asked to design and hold a workshop to identify key non-chemical
stressors, understand the importance of non-chemical stressors within the chemical
paradigm, and consider how chemical and non-chemical stressors should be combined for
analysis. The workshop participants considered holistic decisions on community health
relevant to children and used the Total Environment framework as an organizing construct.
The workshop planning committee was comprised of ORD researchers from both the SHC
and the Air, Climate and Energy (ACE) National Research Programs who were actively
working to incorporate non-chemical stressors into their research portfolios. Workshop
participants were comprised of experts from academia, non-profit organizations, and
government. The workshop included two keynote presentations - first, an overview of EPA
research on non-chemical stressors, and second, an overview of academic research on non-
chemical stressors - as well as a series of subject specific presentations, including non-
chemical stressors and the built environment, natural environment, and social environment
and stressors, and health and well- being. In addition to the presentations, there were a
series of facilitated breakout sessions to allow for more detailed discussions among
workshop participants.
This report summarizes the two-day virtual workshop wholly devoted to non-chemical
stressors within a chemical stressor paradigm.
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This workshop showed that non-chemical stressors from the built, natural, and social
environments are interrelated and influence each other suggesting the challenge of selecting
the most appropriate non-chemical stressors for research within the chemical stressor
paradigm.
Non-chemical stressors from the social environment are inextricably linked to non-chemical
stressors from the built and natural environments. This workshop stressed the importance of
understanding these interrelationships and appropriately incorporating multiple non-chemical
stressors into the chemical stressor paradigm. Many non-chemical stressors co-occur and there
are many combinations of non-chemical stressors depending on the research question. This
workshop identified four of the most important as being geography (e.g., scale, attributes of
places, spatial patterns of phenomena, and interactions among these), neighborhood
environment and characteristics, housing stock, and racism.
This report is organized into three sections: Session Summaries, Summaries of Breakout
Sessions, and Key Takeaways from the Breakout Sessions. The agenda (Appendix A),
participant list (Appendix B), and presentations (Appendix C) are also included as supporting
materials.
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SESSION SUMMARIES
Wednesday. October 6. 2021
Welcome and Introduction
Wayne Cascio, U.S. Environmental Protection Agency
Dr. Wayne Cascio introduced himself, welcomed everyone, and thanked everyone for their
participation in the workshop. Dr. Cascio noted that protecting children's health has always
been a priority at EPA. Children's health is affected by exposures to both chemical and non-
chemical stressors throughout their lifecourse, ultimately affecting educational attainment,
opportunity, and quality of life. There is limited knowledge of the potential for non-chemical
stressors to interact with chemical stressors to yield more substantial and concerning health
effects.
Examples of non-chemical stressors include poverty, inequality, racism, lack of access to food,
and healthcare limitations. There is emerging evidence that non-chemical stressors modify
responses to chemical exposures. Researchers from ORD hosted this workshop to better
understand the plethora of non-chemical stressors and to devote discussion to non-chemical
stressors.
Workshop Goals and Objectives
Nicolle Tulve, U.S. Environmental Protection Agency
Dr. Nicolle Tulve introduced herself, thanked the workshop participants, and described the
purpose of the workshop. Dr. Tulve explained research needs and noted that the workshop will
be used for upcoming research planning. The workshop goals include identifying research
needs focused on the role of non-chemical stressors and exploring the state-of-the-science on
non- chemical stressors within a chemical stressor paradigm as it informs children's
environmental health. The workshop objectives include engaging subject matter experts, using
the Total Environment framework (Tulve et al., 2016) construct, and exploring approaches for
designing research activities. Dr. Tulve outlined the Chemical Stressor and Total Environment
frameworks and their relation to children's health. She also explained the differences between
built, natural, and social environments and between chemical and non-chemical stressors. Dr.
Tulve then reviewed the workshop agenda.
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Keynote: Overview ofEPA's Research on Non-Chemical Stressors
Andrew Geller, U.S. Environmental Protection Agency
Dr. Andrew Geller defined cumulative risk assessment and discussed EPA's approaches,
including standardization of roles, permitting, program delivery prioritization, resource
allocation, and outreach and analysis research. Dr. Geller noted there is concern among
stakeholder groups that EPA's narrow focus on evaluating risks associated with individual
chemicals in the context of regulatory requirements or isolated action does not accurately
capture risks associated with simultaneous exposures to multiple chemical and non-chemical
stressors.
Dr. Geller discussed EPA's current focus on evaluating the total burden on an individual or
community and described ORD's experience with performing traditional single and multiple
chemical risk assessments and in developing various tools to produce assessments for viruses,
pesticides, air quality, toxicity, and polychlorinated biphenyls (PCBs). Dr. Geller discussed
ORD's development of new methods to consider cumulative chemical exposure impacts and
EPA's use of indices to incorporate other domains and allow for a broader understanding of the
environment. Dr. Gellerthen displayed a cumulative impact conceptual diagram illustrating the
complex interactions between components and outlined factors for consideration when
determining cumulative impacts on health, well-being, and quality of life. Dr. Geller noted the
importance of considering stakeholder input when making decisions about interventions.
Dr. Geller next discussed the exposome, providing examples of current outcome-based
research and outlining additional future research issues. Dr. Geller described research on
neighborhood stressors that result in accelerated aging, and research on neighborhood
revitalization demonstrating that multiple health determinants can be addressed during land
revitalization planning and design. Dr. Geller emphasized the importance of a community-
engaged approach for effective neighborhood revitalization and explained how such research
is useful to other programs, policies and decisions, such as brownfields, permitting, or
community capacity.
Dr. Geller concluded that ORD expects cumulative risk, cumulative impacts, and support for
communities with environmental justice (EJ) concerns both nationally and locally to be priorities
within StRAP 4 planning. Dr. Geller's slides are included in Appendix C.
Keynote: Overview of Academic Research on Non-Chemical Stressors
Jennifer Richmond-Bryant, North Carolina State University
Dr. Jennifer Richmond-Bryant provided an overview of the exposome as a tool for studying
childhood exposures. Dr. Richmond-Bryant defined cumulative risk, multiple agents, and
chemical and non-chemical stressors. Dr. Richmond-Bryant provided examples of physical,
biological, and social non-chemical stressors that can be used in a framework to evaluate
health impacts and coping capacity. Dr. Richmond-Bryant described a conceptual model of
exposure assessment in environmental epidemiology, where personal exposure represents
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the entire exposure history, and explained how chemicals interact with psychosocial factors,
receptors, stressors, and internal doses. Dr. Richmond-Bryant noted the difficulty of fully
measuring exposure, the importance of social factors in this model, and the role of pollution
in confounding stress indicators.
Dr. Richmond-Bryant compared the exposome to the human genome and noted that the
exposome has different domains related to health risks and risk across communities. This risk
profile involves interactions between the external environment and the internal environment
to determine a health risk assessment. Within an epidemiology framework, as one moves
from individual to population-level outcomes, layers of data become evident. These layers
include personal attributes, ambient conditions, biological mechanisms, and moderating and
mediating factors.
Dr. Richmond-Bryant next discussed the Exposomics Consortium, which focuses on
technology assessments, multipollutant effect approaches, dose-response relationships,
causal determinations, and general lifecourse epidemiology. The Exposomics study design
includes public health perspectives, characteristics of exposure, and mechanisms for
responding to the exposure. The research process involves assessing individual exposures,
outdoor exposures, integrated molecular exposure signatures, exposome links to child
health, the role of socioeconomic status, and the health impacts of multiple exposures. Dr.
Richmond-Bryant then provided an overview of the Human Early-Life Exposome (HELIX)
study that used models of exposure pathways to analyze large numbers of chemical and non-
chemical stressors and understand child health risk and the burden of childhood disease. Dr.
Richmond-Bryant discussed several other exposome-wide association studies, some
measuring the health effects of pollution and lead.
Dr. Richmond-Bryant concluded her presentation by stating that frameworks exist for
studying cumulative or concurrent ambient and nonambient exposure groupings, models
exist for studying multiple exposures and health effects, models can be used to improve the
validity of results, and these approaches and others can be used to study how chemical and
non-chemical stressors influence children's health. Dr. Richmond-Bryant's slides are included
in Appendix C.
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SUBJECT-SPECIFIC PRESENTATIONS
Non-Chemical Stressors from the Built Environment
Adrienne Hollis, Union of Concerned Scientists
Dr. Adrienne Hollis discussed non-chemical stressors in the built environment and her work
at the intersection of climate change, environmental justice, and health. Dr. Hollis discussed
the relationships between structural racism, race and place, environmental justice issues,
climate change, and environmental stressors that form a syndemic; here a network of issues
that lead to adverse health effects. Dr. Hollis explained how the underlying factor of racism
affects all aspects of life and that environmental racism is not new. Dr. Hollis listed multiple
stressors from the built environment that impact health, including racism, poverty, jobs,
economics, education, infrastructure, food and water scarcity, greenspace, transportation,
extreme weather, displacement, safety, and issues associated with mental and physical
health. Dr. Hollis
emphasized that climate change is an exacerbating factor associated with environmental
justice and human health. Dr. Hollis' slides are included in Appendix C.
Non-Chemical Stressors from the Natural Environment
Susan Yee, U.S. Environmental Protection Agency
Dr. Susan Yee discussed how components of the natural environment impact human health and
well-being. Where ecological and human interactions intersect, the specific attributes of the
natural environment, how those attributes are used, and who benefits are all factors affecting
health and well-being. Dr. Yee discussed ways in which the natural environment might alter the
effect of chemical stressors, including changing exposures, decreasing individual vulnerability to
chemical stressors, and providing natural alternatives that reduce the need for chemicals. Dr.
Yee then discussed a case study in San Juan, Puerto Rico that investigated whether actions to
restore estuary hydrology, wetland habitat, and greenspace might benefit human health and
well-being. The study used a structured decision-making framework to guide the research. Dr.
Yee explained how local communities helped identify the stressors to prioritize for study. Dr.
Yee summarized study results which found that managing the natural environment can benefit
human health and well-being, that the natural environment can provide sustainable alternatives
to chemical use, and that the social and built environment can either exacerbate or buffer
natural environment effects. Dr. Yee's slides are included in Appendix C.
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Non-Chemical Stressors from the Social Environment
Ami Zota, George Washington University
Dr. Ami Zota provided a presentation on integrating intersectionality into the exposome. Dr.
Zota discussed how some communities have successfully integrated environmental justice and
science to drive policy. Dr. Zota discussed racial, ethnic, and socioeconomic inequities
associated with exposures, including to air pollution, polychlorinated biphenyls, lead,
perfluorinated alkyl substances, phthalates and para bens, and flame retardants. Dr. Zota
discussed how an intersectionality exposome framework can help identify health disparities.
Dr. Zota then discussed the Taking Stock study, a community-based research project to
enhance what is known about the products women use every day and how these products
contribute to disparities in health. The study examines product use, exposures, risks, and social
and structural determinants as an environmental justice concern. Dr. Zota concluded by
stating that the intersectionality exposome framework will help achieve environmental justice
by advancing innovation in research, policy, and training. Dr. Zota's slides are included in
Appendix C.
Stressors and Health and Well-Being
Jacqueline MacDonald Gibson, Indiana University
Dr. Jackie MacDonald Gibson discussed a North Carolina case study on access to regulated
water supply in which she has been involved. Dr. MacDonald Gibson described the case study's
research objectives, methods, results, and potential resulting solutions and explained it was
supported by an EPA grant. The project examines racial under-bounding and exclusion from
water service as non-chemical stressors and drivers of chemical stress. Research focuses on
the effects of stressors on children's health and well-being and uses a total environment
framework. Dr. MacDonald Gibson shared results of the study, which indicated that exclusion
from municipal water service increases early-life exposure to lead in drinking water, that
exposure increases adolescent delinquency risk, and that solutions, such as education
intervention, maintaining water filtration, and extending community water service, exist but
are not without problems. Dr. MacDonald Gibson's slides are included in Appendix C.
Thursday. October 7. 2021
Recap of Day 1 and What Is Happening in Day 2
Nicolle Tulve, U.S. Environmental Protection Agency
Dr. Tulve welcomed everyone to the second day of the workshop. Dr. Tulve reviewed the Day 1
presentations and provided a preview of Day 2. Dr. Tulve discussed breakout session logistics
and reviewed the breakout session questions. Dr. Tulve then explained the differences
between built, natural, and social environments before reviewing the workshop schedule and
agenda.
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SUMMARIES OF BREAKOUT SESSIONS
The Total Environment framework is a systems approach for organizing and integrating
chemical and non-chemical stressors, inherent characteristics, and activities and behaviors in
describing health and well-being. Chemical and non-chemical stressors can come from the
built, natural, and social environments, collectively referred to as the total environment
(Tulve et al., 2016). The components of the Total Environment framework are the foundation
for research addressing cumulative impacts (U.S. EPA, 2022).
The emphasis of this workshop was on non-chemical stressors within a chemical stressor
paradigm. This section summarizes the discussions from each of four breakout groups.
Workshop participants were assigned to one of four groups. Each group rotated through
every topic (e.g., non-chemical stressors from the built environment; non-chemical stressors
from the natural environment; non-chemical stressors from the social environment; stressors
and health and well-being). Each breakout session was led by the presenter of that subject-
specific topic, subject matter experts from the workshop planning group, and a facilitator. A
notetaker recorded the discussion in each session. The subject matter experts from the
workshop planning group then distilled the four session discussions into one summary on
that specific topic.
The summaries are organized around the breakout discussion questions:
1. Which non-chemical stressors (from the built, natural, social environments) should
be the focus of research associated with chemical stressors? What is the rationale
for choosing those specific non-chemical stressors?
2. What are the criteria for selecting non-chemical stressors for research within the
chemical stressor paradigm?
3. Which non-chemical stressors are surrogates for other non-chemical stressors or
conditions in the community environment? And how should these stressors be
managed?
4. Which combination of co-occurring non-chemical stressors should be the focus of
research within the chemical stressor paradigm?
Non-Chemical Stressors from the Built Environment
Stressors:
Access issues - healthy food, heat, housing accessibility, information/resources
Climate change - flooding of infrastructure, heat
Displacement
Infrastructure - quality/use, types (housing, storage systems, water infrastructure,
industrialized ag), lighting, placement (proximity to other sites, urban/rural)
Land use and green space, including access to green space and quality of
vegetation around the built environment
Living conditions - heat, lighting, noise, odor, dust
Physical activity
Redlined areas
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Transit - placement, availability, access, traffic
Warnings about not drinking water or swimming in rivers
The workshop participants also discussed the challenges, acknowledging that stressors vary
between populations and settings, and stressors may be beneficial or harmful depending on
these or other characteristics. Stressors can also operate through multiple pathways at the
same time.
It's important to approach this research carefully because there are complex interrelationships
and nuances.
Criteria: There was general agreement that the focus should be on the neighborhood scale and
that it is important to directly engage with communities to ask them what stressors are
important to them. It is also important to think about transferability across communities and
feasibility of defining and measuring stressors. Other ideas included an approach focused on a
logical pathway to drive selection, such as an adverse outcome pathway, and using decision-
based criteria to determine which stressors are most relevant to the program. The value of
engaging social scientists when working with a community to identify health concerns was also
noted. There is not a one-size-fits-all approach, and perhaps a suite of variables can be a
starting point for discussion with a focus group using an open-ended information gathering
approach. We discussed how we might need data before we are able to select pathways of
interest, how many stressors operate through multiple pathways, and how it is challenging to
distinguish between built, natural, and social stressors. A lot of non-chemical stressors
represent mediators or moderators with different source pathways; these are stressors that
ORD should focus on.
Potential surrogates: We discussed noise, heat (or lack thereof), housing, levels of education,
and poverty (e.g., related to quality of the built environment) as potential surrogates, while also
recognizing that everything is interrelated. It is hard to disentangle social stressors from built
environment stressors, and both place and population are important. There might be different
ways to address problems at state or regional levels, and one set of metrics may not be
realistic. The decision (e.g., regulation) may guide the choice of surrogates.
Combinations and co-occurring stressors: Neighborhoods are an ideal unit of analysis;
neighborhood scale can bring focus on stressor combinations and co-occurrence, perhaps
through consideration of housing. We also discussed neighborhood-level exposures, poverty,
and climate change. Thinking about how to pair non-chemical stressors and their impact on the
quantitative piece is key. If we are considering built environment features that people have
subjective reactions to, it is hard to have a systematic definition as different racial and ethnic
groups might have different interpretations of their neighborhoods or housing. The same is true
for poverty, crime, and education levels, and these may be covariates to each other.
Overlapping associations between covariates and associated stressors makes it difficult to
separate them out into impact.
There are also questions about the underlying issues that cause regional differences and we
do not know exactly what those differences represent. There may be challenges if we are
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trying to apply wider scale frameworks nationally. Or there may be a logical group of non-
chemical stressors to consider across the board.
Applying an Adverse Outcome Pathway (AOP) network centered around defined adverse
outcomes and identifying factors affecting those pathways could be another approach to
selecting combinations of non-chemical stressors for research. For example, asthma is an
adverse outcome, and we could map out the various stressors that contribute to asthma and
collectively examine those to determine the most important contributors to reducing asthma.
Above all, our groups emphasized the importance of making progress in understanding the role
of non-chemical stressors and the need to avoid analysis paralysis and letting the perfect be
the enemy of the good.
Facilitated by: Adrienne Hollis, Union of Concerned Scientists; Sarah Mazur, U.S.
Environmental Protection Agency; Angie Shatas, U.S. Environmental Protection Agency;
Michael Nye, U.S. Environmental Protection Agency
Non-Chemical Stressors from the Natural Environment
Stressors:
Biodiversity
Climate change, climate variability, natural disasters, extreme weather events
Ecosystem services
Green and blue space
Noise
Normalized Difference Vegetation Index (NDVI) and other empirical methods
Revitalization of nature
Tree canopy, sunshine, heat, temperature control, walkability (which links to the
built environment)
We discussed the need to focus not just on which stressors to choose but also on mitigating the
stressors and identifying solutions that can impact how communities cope. We identified two
approaches: 1) reduce stressor to reduce harm; and 2) identify and employ interventions. We
need to keep both approaches in mind because addressing an effect without addressing the
source could result in unpredictable results. For the intervention component, we need to
understand the system to know where to intervene, e.g., intervene upstream at the root causes
or choose more immediate interventions. We need to use a translational science approach to
define criteria and types of stressors, and document decision-making behind selected
interventions to improve the science to support decision-making and employ a systematic
approach to target investments to address disparities in those experiencing higher exposures to
non-chemical stressors.
Criteria: There was consensus that the focus should be on generating and using criteria to
prioritize non-chemical stressors for research rather than generating a list. Prioritization
approaches included spending effort thinking about what more we can learn mechanistically
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while also thinking about delivering a program that will have an impact on communities in the
short term. Criteria should be developed around community needs combined with what we
know about the environment. Criteria should include using qualitative research to explore what
communities think are important stressors, employing this research as foundational and likely
the first step in understanding cumulative impacts. Listening to community members provides
contextual insights that researchers do not have.
Potential surrogates: We discussed potential surrogates for the natural environment including:
Green and blue space, their connection with chemical exposures, their ability to
influence vulnerability to exposures, their effect on health and well-being, access and
who benefits, effect on gentrification, displacement, and community cohesion.
Biodiversity as a potential marker of stressors (equivalent to poverty for non-chemical
stressors).
The Normalized Difference Vegetation Index (NDVI).
Climate variability and change and relationship to exposures in the environment
(interactions with air quality, water quality, other chemicals); tracking climate patterns
over the long-term, selecting the right metrics that capture the stress they produce in both
individuals and communities.
Ecosystem services and their benefits.
However, hearing from the community about how they use greenspace is most important to help
develop appropriate surrogate measures.
We examined the concept of resilience and the need to consider stressors, interventions,
and solutions together holistically, and think about strategies that fit into the legal
frameworks to which we are bound. In terms of identifying key stressors, we discussed the
use of conceptual models and building integrative models to conduct more complex
systems research and more human-environment interaction research to identify
interconnections.
One key takeaway is the need to work with communities and treat them as partners.
We discussed the need to balance scientific expertise and local knowledge, and how
natural environment solutions might be particularly challenging to implement.
Combinations and co-occurring stressors: We discussed aggregating data from multiple sources
into a single database, the need to understand how vulnerable populations are affected,
institutional challenges in determining where to focus our efforts, whether to pursue short-
term management versus long-term interventions, and the similarities between the built,
natural, and social environments. We also talked about what we thought the building blocks for
studying non- chemical stressors need to be. We mentioned ecosystem services as a way to
facilitate a shift from focusing solely on chemical stressors to the entire context of people living
in the environment. We discussed vulnerability and our statutory authorities to determine
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issues of immediate concern versus lower priority concerns. We also discussed community
engagement and how to conduct research that promotes community ownership, is mutually
beneficial, and that leaves communities better off.
Facilitated by: Susan Yee, U.S. Environmental Protection Agency; Matthew Harwell, U.S.
Environmental Protection Agency; Susan Julius, U.S. Environmental Protection Agency
Non-Chemical Stressors from the Social Environment
Stressors:
Disability
Discrimination, environmental injustice, historical redlining,
marginalization
Education
Health care
Housing
Low income/social status
Policies
Poverty
Racism
Social cohesion, gentrification
Underserved populations/communities
Social stressors influence and interact with all other components in the Total Environment
framework. They determine how we are exposed to both chemical and non-chemical stressors
from the built and natural environments. For example, racism or discrimination may influence
people's access to safe drinking water, healthy food, or green spaces and may increase
exposures to contaminants like lead found in the built environment. Spatial and temporal
aspects of non- chemical stressors from the social environment are important and must be
considered holistically for cumulative impacts. Policies (e.g., the Supplemental Nutrition
Assistance Program, federal housing assistance) can act as either stressors exacerbating
negative outcomes or as buffers that reduce negative outcomes.
Criteria: We need research that examines both upstream and downstream factors. For
example, if racism is an upstream stressor that leads to residential segregation, which then
affects environmental health, how do we identify the modifiable factors that EPA could/should
address? Those might be things that operate at a downstream level, like geographically
targeted control strategies for sources of pollution that result in higher exposures in
communities of color. This would address a manifestation of segregation and other structural
inequities rather than the root cause. We could also examine effect modifiers and mediators
and other factors that contribute to background processes and affect the dose response. It is
important to have a conceptual model and be outcome driven to make sure that what is being
measured is relevant. Perhaps a chemical- agnostic adverse outcome pathway (AOP) could
point to appropriate non-chemical stressors. For place-based research we need to involve the
community. There is also the need to break new ground on issues such as mental health.
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Potential surrogates: Policies themselves can be surrogates for non-chemical stressors. Our
discussion of surrogates was challenging, but we agreed that policies affect exposures, as
stressors or buffers, and can be health determinants. For example, housing policy affects
exposure to lead-based paint. We are describing a paradigm shift by incorporating social
stressors where factors such as policy influence health determinants and health outcomes, and
these have quantifiable, measurable effects.
In addition to policies, other tools might also be useful, and we must think about what
knowledge will be needed to pursue such tools. We talked about local problem-solving research
where qualitative research can help to shed light on issues and help develop ways to define and
measure stressors. Understanding the role of perception is also important, and an important
role for social sciences, as different groups and individuals perceive potential stressors and how
they affect health differently.
Combinations and co-occurring stressors: We talked about the connection between low-
income minority communities and environmental hazards, and that these are often combined
with elevated exposures to chemicals due to historical and systemic racism. When we examine
pollution levels in different places, we talked about the need to connect those results with
other upstream factors such as racial segregation and historic disinvestment to get at root
causes and address modifiable factors. We discussed how our research could support
cumulative decision making by addressing social and psychological factors that affect health
outcomes. We agreedthat social determinants of health are a suite of factors that should be
addressed when studying the effects of chemical exposures. We also discussed the need to
understand the impact of policies (such as housing policy) and their interactions on economic
and social structures and the potential to ameliorate or exacerbate chemical and non-chemical
stressors. Qualitative research can be used to reveal community needs and be used together
with quantitative research and risk analysis to specify mechanisms and how they affect health
outcomes. We argued that both approaches are needed so that researchers have the context
to understand what drives decisions and actions. To move this research forward, we discussed
the need to take an intersectional perspective and develop integrative models of social
stressors and their interaction with other stressors.
Facilitated by: Ami Zota, George Washington University; Intaek Hahn, U.S. Environmental
Protection Agency; Emily Eisenhauer, U.S. Environmental Protection Agency
Stressors and Health and Well-Being
Stressors:
Access to resources
Geography/geographic specificity (e.g., scale, attributes of places, spatial patterns
of phenomena, and interactions among these)
Housing
Infrastructure, physical structures
Mental health
13
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Parenting (parents as a source of or protection from stressors for their children)
Peer relationships (especially for children)
Racism
School environment
Sleep
Social context
Social isolation
Violence
Differential exposures driven by racism impact peoples' lives and our ability to measure and
evaluate stressors. We also explored social context as a key non-chemical stressor. Geographic
specificity affects infrastructure, housing, and other aspects of the community environment.
Criteria: Every community has a unique combination of non-chemical stressors. We talked
about the actual stressors (only some of which may relate to outcomes), understanding their
range of impact and using a systematic approach to determine what stressors to include. We
discussed the concept of a "mothership of stressors" stemming from multiple interactions
occurring at once that we could use to isolate different downstream non-chemical stressors.
We discussed the idea of threshold effects and whether there is a saturation point after which
people cannot take any more stress and their individual health is compromised and how
resilience affects people's perceived levels of stress. We also discussed methods. We talked
about partnering with communities and strengthening the idea that research should not be
conducted in isolation but with the relevant partners. There is also the need to develop
qualitative guidelines for considering non-chemical stressors, specifically emotional, social, and
political ones. We talked about biomarkers, allostatic load, systems approaches and
computational methods, such as machine learning for managing large datasets. Lastly, we
talked about using causal framework models to select stressors. Overall, we covered a lot of
ground, but one takeaway is that this is an extremely complicated area.
Potential surrogates: Geography (e.g., scale, attributes of places, spatial patterns of
phenomena, and interactions among these) may be a surrogate for several non-chemical
stressors related to the built, natural, and social environments. The neighborhood and its
characteristics could be a surrogate for several non-chemical stressors.
Combinations and co-occurring stressors: We discussed the interrelationships between racism,
geography, policy, the built environment, and health and well-being. Geography is an important
factor when considering many other non-chemical stressors. We argued that lifetime
experiences and causal relationships should be incorporated into our biological models when
exploring health and well-being. We had multiple discussions around guidelines for conducting
science and how non-chemical stressors should be specifically addressed in those guidelines.
Racism, poverty, and lack of resources are co-occurring stressors and we discussed how these
14
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combined stressors would each contribute to vulnerability. There are combinations of non-
chemical stressors related to economics (e.g., income, occupation, education level). We
discussed how the importance of resilience factors into the interrelationships between
chemical and non-chemical stressors.
Animal models may be one way to explore combinations and co-occurring stressors.
Facilitated by: Jacqueline MacDonald Gibson, Indiana University; Nicolle Tulve, U.S. Environmental
Protection Agency; Jonathan Essoka, U.S. Environmental Protection Agency.
15
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CLOSING REMARKS
Maureen Gwinn, U.S. Environmental Protection Agency Bryan Hubbell, U.S. Environmental
Protection Agency
Maureen Gwinn: Because of this important topic of non-chemical stressors, SHC's team
worked closely with our Air, Climate and Energy (ACE) team to develop this content. Thank
you to Nicolle Tulve and her team for compiling this. On Wednesday, we heard six impactful
talks covering non-chemical stressors and their impacts on health and well-being. These laid
the groundwork for discussion and were very well done. The recaps covered consistent
themes of issues related to the impact of structural racism, defining the unit of analysis,
transferability and scalability of this work, and the importance of qualitative and quantitative
research.
Congratulations to everyone who provided input and expertise. This is an important and
timely topic because these are administrative and presidential priorities, and this workshop
has advanced our thinking on the topics. In the research planning cycle, we are at the stage
of refining our outputs in SHC in Topic 3 which has a strong focus on cumulative impacts.
Research Areas 9 and 10 will bring in a lot of what we learned today. We are working with
ACE to coordinate and collaborate as we move forward.
Sherri Hunt: The ACE program is working to address climate and social impact. From what I
have heard today, understanding the fine scale is important to understanding impacts. People
also discussed how climate impacted the natural and built environment, and the topic of
resilience. To broadly cover the ACE program, one topic of focus is understanding air
pollution and climate change and their impacts on human health. Under this topic, Research
Area 1 covers pollution.
We will be working closely with Maureen and her team on deciding what research belongs in
the ACE and SHC plots. I have confidence in our many intelligent scientists and know we will
work hard and creatively. Please review the research planning intranet site. If you have an
idea, please feel free to reach out to me. I am quite optimistic about being able to link things
together.
Maureen Gwinn: The complexity of these interactions between the national research
programs adds a layer of uncertainty when considering to whom you should propose ideas.
We are here to help and make sure nothing falls through the cracks. As a reminder, we plan
to report out from this workshop. It is important to think big. We have a great opportunity to
expand our boundaries.
Nicolle Tulve: Thank you to the facilitators and planners who put this workshop together and
to all the participants. I look forward to speaking with everyone later in the month!
16
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KEY TAKEAWAYS FROM THE BREAKOUT SESSIONS
Environmental protection encompasses both chemical and non-chemical stressors
since it is the lived experience of individuals and communities that influences their
health and well-being. Therefore, a systems approach and integrative model(s) are
essential for incorporating non-chemical stressors into the chemical stressor paradigm
to protect human health and the environment.
The Total Environment framework can be used to organize research focused on
cumulative impacts where all stressors need to be considered. All aspects of the built,
natural, and social environments should be considered when exploring how chemical
and non-chemical stressors influence health, well-being, and quality of life.
This workshop showed that non-chemical stressors from the built, natural, and social
environments are interrelated and influence each other suggesting the challenge of
selecting the most appropriate non-chemical stressors for research within the
chemical stressor paradigm.
Non-chemical stressors from the social environment are inextricably linked to non-
chemical stressors from the built and natural environments. This workshop stressed
the importance of understanding these interrelationships and appropriately
incorporating multiple non-chemical stressors into the chemical stressor paradigm.
Many non-chemical stressors co-occur and there are many combinations of non-
chemical stressors depending on the research question. This workshop identified four
of the most important as being geography (e.g., scale, attributes of places, spatial
patterns of phenomena, and interactions among these), neighborhood environment and
characteristics, housing stock, and racism.
o Non-chemical stressors may be geography-dependent (e.g., non-chemical
stressors in an urban environment may be different than those found in a rural
or suburban environment), reinforcing the importance of place and factors
associated with place when selecting non-chemical stressors,
o Non-chemical stressors from the built environment depend on many factors
including the geographic location, the population of interest, and the construct
of the built environment.
Research on how social stressors may impact health, well-being, and quality of life
should include both upstream causes (e.g., racism, low income, policies) and
downstream outcomes/solutions (e.g., decision-making, intervention, policy(ies) that
would lead to environmental justice and improved health, well-being, and quality of
life).
Research to develop a new approach to cumulative impact assessment based on social
stressors (e.g., social determinants of health) should be developed.
Establish criteria to identify social stressors and develop models that may be
important for the U.S. EPA to consider in its research, regulatory decision-makings,
and remediation/restoration/revitalization practices.
Develop an ontology to classify and categorize social stressors.
17
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Identify non-chemical stressors from the social environment that are reproducible and
transportable between sites in the United States and abroad to characterize social
environments.
Identify non-chemical stressors from the built and natural environments that are
comparable between sites in the United States and internationally.
Identify non-chemical stressors, such as access to greenspace, that can be early flags of
positive (improved health) or negative impacts (gentrification).
Consider ecosystem services within any assessment of chemical exposures to capture
the entire environment within which people live.
Climate change interacts with many chemical and non-chemical stressors to amplify
their impact on health, well-being, and quality of life and therefore needs to be
considered when assessing cumulative exposures.
Conduct studies that explore how policy(ies) should be structured and implemented in
an all-of-government approach to maximize children's health and well-being.
Approaches and methodologies for analyzing quantitative and qualitative data and
information are essential for advancing our understanding of non-chemical stressors
within the chemical stressor paradigm.
This workshop identified resilience, mitigation, and solutions as key concepts when
identifying and exploring non-chemical stressors and their applicability to understanding
health, well-being, and quality of life outcomes.
18
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REFERENCES
Tulve NS, Ruiz JDC, Lichtveld K, Darney SP, Quackenboss JJ. Development of a conceptual
framework depicting a child's total (built, natural, social) environment in order to optimize
health and well-being. Journal of Environment and Health Sciences 2016; 2(2): 1-8.
https://doi.org/10.15436/2378-6841.16.1121.
U.S. EPA. Cumulative Impacts Research: Recommendations for EPA's Office of Research and
Development. Washington, D.C.: U.S. EPA; 2022.
https://www.epa.gov/healthresearch/cumulative-impacts-research.
19
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APPENDIX A: AGENDA
United States Environmental Protection Agency
Evaluating Non-Chemical Stressors for Children's Environmental Health Protection
Virtual Workshop Summary Meeting Agenda - October 6-7,2021 Virtual
Wednesday, October 6, 2021
Time (EDT)
Topic
Speaker
9:45-10:00 AM
Sign on, Technology Check
Contractor
10:00-10:15 AM
Welcome and Introduction
Set the Stage
Wayne Cascio, U.S. EPA
Chris Frey, U.S. EPA
10:15-10:30 AM
Workshop Goals and Objectives
Nicolle Tulve, U.S. EPA
10:30-11:30 AM
Keynote: Overview of EPA's Research on Non-
Chemical Stressors
Andrew Geller, U.S. EPA
11:30AM-12:30 PM
Keynote: Overview of Academic Research on Non-
Chemical Stressors
Jennifer Richmond-Bryant,
North Carolina State University
12:30-12:45 PM
Q&A, Discussion, Brainstorming Time on Mural
All
12:45-1:30 PM
Lunch Break, Brainstorming Time on Mural
All
1:30-2:30 PM
Subject Specific Presentations & Q&A
1. Stressors and Health and Weil-Being
2. Non-Chemical Stressors from the Natural
environment
Jacqueline MacDonald Gibson,
Indiana University
Susan Yee, U.S. EPA
2:30-2:35 PM
Q&A, Brainstorming Time on Mural
All
2:35-2:45 PM
Break, Brainstorming Time on Mural
All
2:45-3:45 PM
Subject Specific Presentations & Q&A
3. Non-Chemical Stressors from the Social
environment
4. Non-Chemical Stressors from the Built
Environment
Ami Zota, George Washington
University
Adrienne Hollis, Union of
Concerned Scientists
3:45-4:45 pm
Q&A, Discussion, Brainstorming Time on Mural
All
4:45-5:00 PM
End of Day Regroup
Facilitators, Workshop Planning
Group
5:00 PM
Adjourn
Thursday, October 7,2021
Time (EDT)
Topic
Facilitator
9:30-9:45 AM
Sign on, Technology Check
Contractor
9:45-10:00 AM
Recap of Day #1 and What's Happening in Day #2
Nicolle Tulve
10:00-11:00 AM
Breakout Session 1:
1: Non-Chemical Stressors from the Built
Environment
SMEs: Adrienne Hollis, Sarah Mazur, Angie Shatas,
Michael Nye
Jeri Weiss
Time (EDT)
Topic
Facilitator
A-l
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Contractor Support: Karen Setty (SME), Leah West
(Zoom logistics; detailed notetaker)
2: Non-Chemical Stressors from the Natural
Marty Chintala
Environment
SMEs: Susan Yee, Matthew Harwell, Susan Julius
Contractor Support: Samantha Snow (SME), Grace
Cooney (Zoom logistics; detailed notetaker)
3: Non-Chemical Stressors from the Social
Karen Goldberg
Environment
SMEs: Ami Zota, Intaek Hahn, Emily Eisenhauer
Contractor Support: Lisa Prince (SME), Afroditi
Katsigiannakis (Zoom logistics; detailed
notetaker)
4: Stressors and Health and Well-Being
Claudia Gutierrez
SMEs: Jacqueline MacDonald Gibson, NicolleTulve,
Jonathan Essoka
Contractor Support: Jess Wignall (SME), Kathryn Van
Artsdalen (Zoom logistics; detailed
notetaker)
11:00-12:00 PM
Breakout Session 2:
1: Non-Chemical Stressors from the Built
Jeri Weiss
Environment
SMEs: Adrienne Hollis, Sarah Mazur, Angie Shatas,
Michael Nye
Contractor Support: Karen Setty (SME), Leah West
(Zoom logistics; detailed notetaker)
2: Non-Chemical Stressors from the Natural
Marty Chintala
Environment
SMEs: Susan Yee, Matthew Harwell, Susan Julius
Contractor Support: Samantha Snow (SME), Grace
Cooney (Zoom logistics; detailed notetaker)
3: Non-Chemical Stressors from the Social
Karen Goldberg
Environment
SMEs: Ami Zota, Intaek Hahn, Emily Eisenhauer
Contractor Support: Lisa Prince (SME), Afroditi
Katsigiannakis (Zoom logistics; detailed
notetaker)
4: Stressors and Health and Well-Being
Claudia Gutierrez
SMEs: Jacqueline MacDonald Gibson, NicolleTulve,
Jonathan Essoka
Contractor Support: Jess Wignall (SME), Kathryn Van
Artsdalen (Zoom logistics; detailed
notetaker)
12:00-12:15 PM
Discussion, Q&A, Brainstorming Time on Mural
All
12:15-1:00 PM
Lunch Break
All
1:00-2:00 PM
Breakout Session 3:
1: Non-Chemical Stressors from the Built
Jeri Weiss
Environment
SMEs: Adrienne Hollis, Sarah Mazur, Angie Shatas,
Michael Nye
A-2
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Time (EDT)
Topic
Facilitator
Contractor Support: Karen Setty (SME), Leah West
(Zoom logistics; detailed notetaker)
2: Non-Chemical Stressors from the Natural
Environment
SMEs: Susan Yee, Matthew Harwell, Susan Julius
Contractor Support: Samantha Snow (SME), Grace
Cooney (Zoom logistics; detailed notetaker)
3: Non-Chemical Stressors from the Social
Environment
SMEs: Ami Zota, Intaek Hahn, Emily Eisenhauer
Contractor Support: Lisa Prince (SME), Afroditi
Katsigiannakis (Zoom logistics; detailed
notetaker)
4: Stressors and Health and Well-Being
SMEs: Jacqueline MacDonald Gibson, NicolleTulve,
Jonathan Essoka
Contractor Support: Jess Wignall (SME), Kathryn Van
Artsdalen (Zoom logistics; detailed
notetaker)
Marty Chintala
Karen Goldberg
Claudia Gutierrez
2:00-3:00 PM
Breakout Session 4:
1: Non-Chemical Stressors from the Built
Environment
SMEs: Adrienne Hollis, Sarah Mazur, Angie Shatas,
Michael Nye
Contractor Support: Karen Setty (SME), Leah West
(Zoom logistics; detailed notetaker)
2: Non-Chemical Stressors from the Natural
Environment
SMEs: Susan Yee, Matthew Harwell, Susan Julius
Contractor Support: Samantha Snow (SME), Grace
Cooney (Zoom logistics; detailed notetaker)
3: Non-Chemical Stressors from the Social
Environment
SMEs: Ami Zota, Intaek Hahn, Emily Eisenhauer
Contractor Support: Lisa Prince (SME), Afroditi
Katsigiannakis (Zoom logistics; detailed
notetaker)
4: Stressors and Health and Well-Being
SMEs: Jacqueline MacDonald Gibson, NicolleTulve,
Jonathan Essoka
Contractor Support: Jess Wignall (SME), Kathryn Van
Artsdalen (Zoom logistics; detailed
notetaker)
Jeri Weiss
Marty Chintala
Karen Goldberg
Claudia Gutierrez
3:00-3:15 PM
Break
3:15-4:15 PM
Preliminary high-level report out from each
breakout session
4:15-4:45 PM
Closing remarks
Maureen Gwinn, U.S. EPA
Bryan Hubbell, U.S. EPA
4:45 PM
Adjourn
A-3
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APPENDIX B: PARTICIPANTS
U.S. Environmental Protection
Caroline Baier-Anderson
Timothy Barzyk
Ann Carroll Marty
Chintala Emily
Eisenhauer
Jonathan Essoka
Aimen Farraj
Michael Firestone
Stiven Foster
Andrew Geller
Karen Goldberg
Tywanna Greene
Carol Ann Gross-Davis
Claudia Gutierrez
Maureen Gwinn
Intaek Hahn
Agency Attendees:
Matthew Harwell
Cheryl Hawkins
Joel Hoffman
Adrienne Hollis
Bryan Hubbell
Sherri Hunt
Annie Jarabek
Sabrina Johnson
Susan Julius
Urmila Kodavanti
Charles Lee
Nicholas Loschin
Tom Luben
Sarah Mazur
Onyemaechi Nweke
Michael Nye
Beth Owens
Sean Paul
Elizabeth Poole
Steven Prince
Kristen Rappazzo
Victoria Robinson
Angie Shatas
Sheryl Stohs
Danielle Suarez
John Thomas
Nicolle Tulve
Jeri Weiss
Kathleen Williams
Susan Yee
Other Attendees:
Juan Antonio Aguilera
Mendoza
Allison Appleton
Jane Clougherty
Deborah A. Cory-Slechta
Pam Factor-Litvak
Akhgar Ghassabian
Perry Hystad
Chandra Jackson
Jonathan Levy
Jacqueline MacDonald
Gibson
Hilary Marusak
Meredith McCormack
Junenette L. Peters
Jennifer Richmond-Bryant
Isadore Leslie Rubin
Tina Sindher
Ami Zota
Contractor Support:
Canden Byrd
Grace Cooney
Anthony Hannani
Afroditi Katsigiannakis
Lisa Prince
Megan Rooney
Karen Setty
Samantha Snow
Kathryn Van Artsdalen
Leah West
Jess Wignall
B-l
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APPENDIX C: PRESENTATIONS
*>EPA
Cumulative Assessment
including
Non-chemical Stressors
Andrew M. Geller, Ph.D.
Office of Research and Development, U.S. EPA
October 6, 2021
l
i&EPA Range of Needs and Assessments
Assessment of cumulative impacts or risks can be useful for different types of decisions.
Figure 2. Spectrum of EJ Integration Approaches,
Using a "Fit-for-Purpose" Continuum
From Confronting Disproportionate Impacts and Systemic Racism in Environmental Policy.
2 Charles Lee. (51) Environmental Law Reporter. 2021.
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v>E
PA Cumulative Risk Assessment
1
Cumulative Risk Assessment: An analysis,
characterization, and possible
quantification of the combined risks to
human health or the environment from
M
multiple agents or stressors (U.S. EPA
2003)
3
EPA Publications on CRA
EPA Publication
Guidelines for the Health Risk Assessment of Chemical Mixtures (U.S. EPA 1986b)
Supplementary Guidance for Conducting Health Risk Assessment of Chemical Mixtures (U.S. EPA 2000c)
Conducting a Risk Assessment of Mixtures of Disinfection By-Products (DBPs) for Drinking Water Treatment Systems (U.S. EPA
2000a)
Risk Assessment for Superfund Sites (RAGS) (U.S. EPA 1989)
Guidelines for Ecological Risk Assessment (U.S. EPA 1998a)
Guidance on Cumulative Risk Assessment. Part 1. Planning and Scoping (Browner 1997; U.S. EPA 1997a)
Lessons Learned on Planning and Scoping for Environmental Risk Assessments (U.S. EPA 2002c)
General Principles for Performing Aggregate Exposure and Risk Assessments (U.S. EPA 2001a)
Guidance on Cumulative Risk Assessment of Pesticide Chemicals That Have a Common Mechanism of Toxicity (U.S. EPA 2002a)
Framework for Cumulative Risk Assessment (U.S. EPA 2003b)
A Framework For Assessing Health Risk of Environmental Exposures To Children (U.S. EPA 2006c)
Concepts, Methods, and Data Sources for Cumulative Health Risk Assessment of Multiple Chemicals, Exposures and Effects (U.S.
EPA 2007a)
4
Framework for Human Health Risk Assessment to Inform Decision Making (U.S. EPA 2014b)
Pesticide Cumulative Risk Assessment: Framework for Screening Analysis (U.S. EPA 2016)
C-2
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Risk assessment applications in EPA "are often centered
on evaluating risks associated with individual chemicals
in the context of regulatory requirements or isolated
actions..."
There is concern "among stakeholder groups (especially
communities affected by environmental exposure) that
such a narrow focus does not accurately capture the
risks associated with exposure, given simultaneous
exposure to multiple chemical and nonchemical
stressors and other factors that could influence
vulnerability."
Advancing Ui*k Aftseasnient
KATK*i*i O.VAJTH CCXMCA
SEPA Cumulative Impact Assessment
Cumulative Impacts:
*z2S2p>
Risks and impacts caused by multiple pollutants, both
in isolation and through their interaction with each
other and social vulnerabilities. The pollutants are
usually emitted by multiple sources located in the
community. _
*
From presentation by Dr Nicky Sheats and Dr Ana Baptista
C-3
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Cumulative Impact Assessment
EO14008: Tackling the Climate Crisis at Home and Abroad
We must listen to science and act.
Agencies shall make achieving environmental justice part
of their missions ... to address the disproportionately
high and adverse human health, environmental,
climate-related and other cumulative impacts on
disadvantaged communities, as well as the
accompanying economic challenges of such impacts
Application of Cumulative Impact Assessment:
New Jersey Statute S232
If a facility seeking a permit would cause higher cumulative
environmental and public health stressors, then:
New permit: Denied
Expansion: Additional Conditions
Renewal: Additional Conditions
An applicant must prepare:
"...an environmental justice impact statement that assesses
the potential environmental and public health stressors
associated with the proposed new or expanded facility,... and
the environmental or public health stressors already borne
by the overburdened community as a result of existing
conditions located in or affecting the overburdened
community"
Locations with EJ Policies
Locality
Types of Policies
Austin. TX
Proactive Planning
Baltimore, MD
Bars
Camden City. NJ
Reviews
Chicago, IL
Bans, Health Codes
Cincinnati. OH
Reviews
Commerce, CA
Proactive Planning
Detroit, Ml
Health Codes
Denver. CO
Health Codes
Erie. CO
Health Codes
Eugene. OR
Proactive Planning
Fulton County, GA
Proactive Planning, Reviews, General
Huntington Park, CA
Targeted
Los Angeles, CA
Proactive Planning
Los Angeles County, CA
Proactive Planning
Minneapolis, MN
Proactive Planning, Targeted
National City, CA
Proactive Planning, Targeted
Newark. NJ
Reviews
New York, NY
General
Oakland, CA
Bans
Portland, OR
Bans
Richmond. CA
Health Codes
San Francisco, CA
General, Targeted, Proactive Planning. Health
Codes, Reviews
Seattle. WA
Proactive Planning, Bans
Washington, D.C.
Proactive Planning, Targeted
Whatcom County, WA
Bans
https://ehsdaiiyadvisor.blr.com/2021/06/cumulative-
i m pa ct-ord i na n ces-a dd ress-e n vi ron m en ta I -j ustice/
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Cumulative Assessment-Chemical arid Non-Chemical
Stressors
Traditional Risk Assessment
EPA and ORD have much experience with
source-to-outcome chemical risk assessment.
Community-
From Environmental Justice Research Roadmap EPA 601/R-16/006 (2016)
Risk to Chemical Mixtures:
Total Petroleum Hydrocarbon (TPH)
Question: How can we develop toxicity values for chemical mixtures that reflect real-life exposures,
account for the variability in the mixture, and are measurable in the environment?
Methods:
Environmental contamination by complex TPH mixtures is
widespread; TPH mixture components are poorly defined
and often vary across sites and over time
The TPH Provisional Peer-Reviewed Toxicity Value
(PPRTV) assessment uses a fraction-based approach.
Examines integrated noncancer hazard or cancer risk
associated with exposure to six fractions defined by
chemical properties, Lessons Learned:
Using a data-driven approach, the choice
Methods used: indicator chemical approaches; hazard of method for determining the risk of the
index method; relative potency factor approach; mjxture depen(js Qn the chemjca| ana|yses
10 integrated addition method; response addition approach conducted at the site
C-5
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V
Chemical Co-Exposure Modeling
Question: How can we identify and characterize potential real-
world chemical co-exposures from consumer products to
prioritize in vitro toxicity screening for regulatory decisions?
Methods: Computational modeling methods to link chemical
ingredients in consumer products to household level consumer
product purchasing data
Lessons Learned:
Patterns of chemical co-occurrence identified across all
households, including when stratifying on race/ethnicity, income,
education, and family composition
Humans are potentially exposed to many chemicals from the
use of consumer products
Exposure includes a combination of chemicalsfrom different
products
Computational methods may be used to help prioritize chemical
combinations for toxicity testing
.I
, งCP!>*t
itaBClwmfcjl 501
uoauced touch
[h Product Puichawi
^ f rซquซ nt inmut Mining
Cumulative Assessment-Chemical and Non-Chemical
Stressors
Aggregate Exposure Pathway (AEP)
Manufacturing
Industrial by-products
Food production
External |
Exposure
Food & Drink
Air, water, dust
Consumer
products
Internal
Exposure
Teeguarden, Tari et al (2016)
Approaches
Estimation from whole
mixture testing results
Assumptions of dose
additivity
Assumptions of response
additivity
ORD is developing methods to consider
cumulative chemical exposures incorporating
AEPs linked to AOPs
Applications of chemical mixtures research
include updating assessments on PCBS,
characterizing PFAS mixtures, and
considering provisional toxicity values for
Total Petroleum Hydrocarbons
~]g4> '
Ankley et al. (2010); Villeneuve et al. (2014)
Adverse
Outcome
Regulatory-
Relevant
Population
Responses
Adverse Outcome Pathway (AOP)
C-6
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sX_
Cumulative Assessment - Chemical and Non-chemical
Stressors
Traditional Risk Assessment
How do we go from this
traditional chemical risk
assessment paradigm...
Community-
From Environmental Justice Research Roadmap EPA 601/R-l6/006 (2016)
Cumulative Risk Assessment
Traditional Risk Assessment
...to this paradigm that
incorporates non-
chemical stressors that
undoubtedly play a
role in disparate
exposures and health
outcomes?
| Race/Ethnicity | - ป| Residential Location
Neighborhood
Community
Structural
Environmental
Resources
Stressors
Factors
Hazards and
\
Pollutants
Modified from Gซ and Poyne-Sturgti. 20O9.
Environ Hrolth Penpta. 112(17): 1615-1653
From Environmental Justice Research Roadmap EPA 601/R-16/006 (2016)
-------
Positive/Neutral/N =b<".ivc
Influences on Total (Bu It, Natural,
Social) Environ ents
15
Adapted from Tulve, N. S., Ruiz, J. D.,
Lichtveld, K., Darney, S. P., &
Qsickenboss, J. J. (2016).
Stelopment of a conceptual
pmework depicting a child's total
(Jilt, natural, social) environment
order to optimize health and well
bang. Journal of Environment and
Health Science, 2(2), 0-0.
1
SEPA ~
Chemical and Non-Chemical Stressors - The Total
Environment / Exposome
1
Outcome-based research:
Total Environment (Tulve, et al):Chemical and non-
chemical stressors affecting children: Systematic review
and meta-analysis of: obesity, general cognitive ability,
ADHD, childhood externalizing behaviors
Identifying biomarkers of allostatic load:
Can these serve to operationalize the exposome?
How to quantify social stress to use together with these
biomarkers?
Utility of constructs such as embodiment (Krieger) and
weathering (Geronimus)
Use of qualitative data?
Additional future research issues:
Application of exposome to lifestage research
Application to community-engaged research and public
health
Application to regulatory determinations
16
Exposome: The cumulative measure of environmental
influences and associated biological responses throughout
the lifespan, including exposures from the environment,
diet, behavior, and endogenous processes (Miller and
Jones, 2014)
Ecosystems
Food outlets, alcohol outlets
Built environment and
urban land uses
Population density
Walkabikty
Green/blue space
Social
Household income
Inequality
Social capital
Social networks
Cultural norms
Cultural caprtal
Psychological and mental stress
Vermeulen et al 2020
Physical-Chemical
Temperature/humidity
Electromagnetic fields
Ambient light
Odor and noise
Point, line sources. e.g.
factories, ports
Outdoor and indoor at
pollution
Agricultural activities,
livestock
PoUen/moW/furgus
Pest icdes
fragrance products
flame retardants (PBOts)
Persistent organic pollutants
Plastic and piastcuers
food contaminants
Soil contaminants
Or*1 lung water contamination
Groundwater contamination
Surface water contamination
Occupational exposures
C-8
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17
Neighborhood Environment, Accelerated
Aging, and Air Pollution
Questions:
What is the cumulative impact of multiple neighborhood stressors on accelerated
aging?
How might accelerated aging and air pollution jointly increase cardiovascular health
risks?
Methods:
DNA methylation biomarkers to assess accelerated epigenetic aginga means of
assessing biological age using DNA methylation Biological age is responsive to
environmental exposures and physiological changes and reflects future disease risks
17 neighborhood built environment variables were evaluated by trained assessors and
models for air quality
3 cohorts: Detroit, Ml, and Central NC
Lessons Learned:
The neighborhood environment had a strong impact on accelerated epigenetic aging
that was independent of neighborhood perception
There was a significant interaction between accelerated aging and traffic-related air
pollution indicating that those with accelerated aging may be at increased
environmental health risks
Neighborhood Revitalization,
Cumulative Impact Optimization
Question:
How to revitalize a neighborhood in Rockford, IL?
Optimize health determinants: housing, neighborhood, greenspace,
employment / economy, safety, well-being
Minimize negative impacts, maximize positive impacts as part of a Land
Revitalization Technical Assistance Grant
Method: Health Impact Assessment (HIA)
Scoping-What are impacts? Who is impacted? Who can intervene?
Assessment - Baseline conditions, metrics, indicators
Strategies and Interventions-to improve public health
Communications - based on stakeholder needs
Evaluation and Monitoring - evaluate decision-making and monitor long-term effects
Lessons Learned:
Multiple health determinants (i.e., cumulative impacts) can be
addressed during land revitalization planning and design
This can extend to other programs, policies and decisions, such as
brownfields, permitting or community capacity
18
C-9
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&EPA Conclusions
ORD expects cumulative risk, cumulative impact, arid support for EJ communities to be a priority issues
within its updated research plans.
At the national regulatory scale, for cumulative risk assessment, better methodologies are needed for
public health application of exposures considered broadly
At the local scale, assessment of conditions that combine social and lifestage vulnerability with
environmental conditions for application to environmental decisions that directly affect health and well -
being in those communities are needed
EPA has some tools for rapidly screening communities and locations.
Health Impact Assessments (HIAs) provide one approach to community-engaged cumulative
assessment and structured decision-making
EPA is conducting some foundational research on how different sociodemographic and other factors
impact risk from chemicals or pollutants.
C-10
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NC STATE UNIVERSITY
College of Natural Resources
The Exposome as a Tool for
Studying Childhood Exposures
Jennifer Richmond-Bryant
October 6, 2021
NC STATE UNIVERSITY
College of Natural Resources
Cumulative Risk Assessment
EPA (2003) Framework for Cumulative Risk Assessment:
Cumulative risk: The combined risk from aggregate exposures to multiple
agents or stressors
Cumulative risk assessment: An analysis, characterization, and possible
quantification of the combined risks to health or the environment from
multiple agents or stressors
Multiple agents or stressors
Chemicgl stressors
Non-chemicgl stressors
C-ll
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NC STATE UNIVERSITY
College of Natural Resources
Nonchemical Stressors
Physical
Social
Noise
Poverty
Vibration
Racism/ethnocentris
Heat
m
Humidity
Sexism
Violence
Homophobia
Viruses
Food deserts
Bacteria
Lack of greenspace 2
NC STATE UNIVERSITY
Psvchosocial Stressors
External Stressor
Poverty
Unemployment
Discrimination
Illness
Family issues
Violence
Coping
Capacity
Overwhelmed
College of Natural Resources
Health
Hypothalamus
Corticotrophin
releasing factor
Payne-Sturges DC et al. Methods for evaluating the combined
effects of chemical and nonchemical exposures for
cumulative environmental health risk assessment. tJERPH.
Autonomic Nervous
. System.
HRV
Downstream
Effects
Cortisol
Cortisol
Pituitary
1 1 Adrenocorticotrophi
c hormone
C-12
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NC STATE UNIVERSITY
College of Natural Resources
Conceptual Model of Exposure Assessment in
Environmental Epidemiology
Personal exposure
may represent the
entire exposure
history
- True exposure can never
fully be measured
- Social/Psychosocial factors
National Research Council. Exposure Science in the 21st Century: A Vision and
Metabolic genes.
Susceptibility genes
age, gender, other
and other risk factors
modifying factors
(for example, age,
comorbidity conditions)
Solid lines = direct effects, dashed lines = modifiers
NC STATE UNIVERSITY
College of Natural Resources
Characterizing Stressors in a CRA Model
Direct Stressor
(Additive/Confounder) Modifier (Interaction)
Stress
Indicators
Pollution
p
Heal
Effe
Stress
Indicators
Y = p0 + Px*X + ps*Stressor + Pc*Z + s
Hajat Aetal. Confounding by socioeconomic status in epidemiological studies of air pollution and
health: Challenges and opportunities. Environ Health Perspect. 2021; 129:065001
Pollution
Y = po + P'*X*Stressor + pz*Z + a
C-13
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NC STATE UNIVERSITY
College of Natural Resources
The "Exposome" Concept (Wild, 2005)
Represents total, cumulative exposures from in utero onward
Chemical
Nonchemical
Analogy to the human genome, as a map of the proteins
determining human traits
Calls attention to need for more detailed exposure information,
like the genome fingerprint
Popular concept: new journal "Exposome" founded 2021
Wild CP. Complementing the genome with an "exposome": The outstanding challenge of environmental measurement in molecular epidemiology. Cancer Epidemiol ฃ
Biomarkers Prev. 2005;! 4(8): 1 847-1 850.
NC STATE UNIVERSITY
College of Natural Resources
The Exposome Analogy
Human Genome
a
base pairs
sugar-phosphate
backbone
_ ~ 3HQ nitrogen-
containing
\ / sugar [E bases
D 2007 Encyclopaedia Britannica, Inc.
Exposome
(
Tooacco |
https://www.britannica.com/event/Human-Genome-
Vrijheid M. The exposome: a new paradigm to study the impact of
environment on health. Thorax. 2014;69:876-878.
C-14
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NC STATE UNIVERSITY
College of Natural Resources
-Omic Model for Health
All of the "omics"
impact human
health
The exposome impacts
all others
Exogenous
- Some of which are
DNA sequence
Environment Body
Siroux V, Agier L, Slama R. The exposome concept: A challenge and a potential driver for
environmental health research. Eur Respir Rev. 2016;25:104-107.
NC STATE UNIVERSITY
The Exposome
Three domains:
General external environment
(community): e.g., ambient air,
climate, social status
Specific external environment
(individual): e.g., smoking, diet,
indoor air, exercise
Internal environment: e.g.,
oxidative stress,
College of Natural Resources
Vrijheid M. The exposome: a new paradigm to study the impact of
environment on health. Thorax. 2014;69:876-878.
C-15
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NC STATE UNIVERSITY
College of Natural Resources
The Exposome in an Epidemiology
Framework
As one moves from the
individual to population
outcomes, layers of
Personal attributes
Ambient conditions in
the natural, built, social,
and policy environment
Biological mechanisms
Moderating and
mediating factors
NC STATE UNIVERSITY College of Natural Resources
EXPOsOMICS Consortium:
Framing Questions
Can personal exposure and -omic technologies be used to refine exposure
assessment for air and water contaminants?
Will more accurate estimates with reduced exposure measurement error
result?
Do new approaches allow for investigating multipollutant effects?
Does the exposome improve the study of dose-response relationships?
Can exposome analysis strengthen the process of making causal
determinations?
Can exposomics be used to study life-course epidemiology?
Turner MC et al. EXPOsOMICS: Final policy workshop and stakeholder consultation. BMC Public Health. 201 8; 1 8:260.
INDIVIDUAL
PERSONAL ATTRIBUTES
Demographics
Behaviors
ฆ Psychosocial
ENVIRONMENT
" HISTORICAL
FIGURE 11 Applying an exposome approach to cardio-vascular disease onset, progression, and outcomes.
MODERATING
FACTORS
So
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NC STATE UNIVERSITY
College of Natural Resources
Exposomics Study Design Considerations
* Public health perspectives: health effects of
exposures, regulations, prevalence among population
* Characteristics of the exposure: level, averaging
time, frequency, dose
* Mechanism of responding to the exposure:
toxicokinetics, additivity or synergism
12
DeBord et al. Use of the "exposome" in the practice of epidemiology: A primer on omic technologies. Am J Epidemiol. 2016;1 84:302-314.
NC STATE UNIVERSITY College of Natural Resources
Exposomics: Research Process
1. Assess individual exposures
2. Assess outdoor exposures
3. Integrate exposures
4. Integrate molecular exposure signatures
5. Link exposome to child health
6. Identify health impacts of multiple exposures
C-17
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NC STATE UNIVERSITY
College of Natural Resources
Approaches to Generating an
Exposome Metric
Create matrix of correlations
between all variable pairs
Compute closest positive definite^
matrix
Benchmark correlation matrix, I
Use the matrix to generate the
exposome, X ~ N(0/1)
a# .i# . - 'A
W/////M \\\\\\
5 **ซฆฆฆซ** -
Correlation
0.5 > r > = 0.3 -0.3 <= r < -0.5
Families of Exposure
Metals
Organochlorines
Water Pollutants
Home Environment
Air Pollutants
Phthalates
Bisphenol A
Built Environment
PFAS
PBDEs
Temperature
Noise
Cotinine
Agier L et al. A systematic comparison of linear regression-based statistical
methods to assess exposome-health associations. Environ. Health Perpsect.
2016;124:1848-1856
Robinson O et al. The Pregnancy Exposome: Multiple environmental exposures in
the INMA-Sabadell Birth Cohort. Environ Sci Technol. 2015;49:10632-"| 1 40641.
NC STATE UNIVERSITY
College of Natural Resources
Approaches to Modeling Effects of
the Exposome
Different models can be developed depending on assumptions
for environmental factors, e.g.,
Linearity: Y = Xkj=l f3\Xi + 6, e ~ N (0, a2 )
- Interactions: Y = ฃk frXi + ฃk ฃji2 Ji,jXtXj + e, ~ TV 0,a2 )
i=l
i=l
Multiple comparison testing (^xWA|, exposome-wide association study):
Y = (30 + P\X\ + 6,-6 ~ N 0,
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NC STATE UNIVERSITY
College of Natural Resources
Approaches to Modeling Effects of
the Exposome
Several methods are designed to curtail collinearity among the
environmental factors
Two-step Environment-Wide Association Study (EWAS2): univariate
regression for each factor with multiple comparison p-value adjustment,
then significant factors from the univariate regression get included in a
multivariate model with interactions
Deletion/Substitution/Addition: variable selection, with main effects and
interactions
Sun 3-step Method: Check for correlations (e.g., p > 0.6) and keep most
significant, then run selected variables through a CART
Barrera-Gomez J et al. A systematic comparison of statistical methods to detect interactions in exposome-health associations. Environ Health. 2017; 16:74.
NC STATE UNIVERSITY College of Natural Resources
Approaches to Modeling Effects of
the Exposome
Other methods allow for collinearity (no independence)
Least Absolute Shrinkage and Selection Operator (LASSO): minimizes
RSS penalized by sum of absolute value of regression coefficients, in
many cases driving /? ^ 0
Elastic Net (ENET): a variation on LASSO using a second penalty
Group-LASSO INTERaction-NET (GLINTERNET): follows LASSO design
but also allows for pair-wise interactions for non-zero regression
coefficients
Boosted Regression Trees (BRT): iterative process of partitioning data,
fitting regression, and then classifying data until optimized
Barrera-Gomez J et al. A systematic comparison of statistical methods to detect interactions in exposome-health associations. Environ Health. 2017; 16:74.
C-19
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NC STATE UNIVERSITY
College of Natural Resources
Exposomics and Children's Health
Human Early-Life
Exposome (HELIX) study:
- Aggregated data from six
early life studies
conducted across Europe
- 31,472 children participated
in total
- Women recruited during
pregnancy at different
trimesters, depending on
1. Measuring the external exposome
Repeat
biomarkers,
questionnaires,
exposure
monitors, and
models
Food
contaminants
Consumer
products
Water
contaminants
Indoor air
pollutants
GIS/spatial
models,
remote
sensing,
exposure
monitors,
smart phones
Outdoor air
pollutants
Built
environmental
green space;
2. Integrating the external
and internal exposome
3. Impact on child health
Individual
exposures
(area 1)
Reducing
uncertainty
1
Outdoor
exposures
(area 2)
Reducing
uncertainty
Integrating
exposures
(area 3)
Multiple
exposure
patterns
Integrating
molecular
signatures
(area 4)
Omics
tools,
pathway
analysis
Child
health
risk
(area 5)
Statistical
tools for
multiple
exposures
Individual and temporal variability
physical activity, mobility, diet social
Environmental
burden of
childhood
disease
(area 6)
Impact
assessment
for multiple
exposures
Vrijheid, M et al. The Human Early-Life Exposome (HELIX): Project
Rationallegand Design. Environ Health Perspect. 2014;122:535-544.
NC STATE UNIVERSITY
College of Natural Resources
Exposomics in Children: Exposures to Chemical
and Nonchemical Stressors
Group
H il-noipn-sric txillutdnls
Surrounding natural spac
Meteorology
ฆ BuUt EfMroflmcflt
ฆ PBOEs
PFASs
O Metals
- = PhBWatM
H Pftsnois
I aDacca snoBmfl
| Water DBPs
H tifostjle
Mean of principal component score
Tamayo-Uria I et al.The early-life exposome: Description and patterns in six European countries.
Environment International. 2019;123:189-200.
PCA used to analyze large
numbers of stressors
(chemical and non-chemical)
87 during pregnancy
1 22 during childhood
Reduced to 1 5 groupings:
Atmospheric pollutants
Surrounding natural space
Meteorology
Built environment
Traffic
Road traffic noise
Etc.
19
C-20
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NC STATE UNIVERSITY
College of Natural Resources
B
Exposomics in Children: Exposures to Chemical
and Nonqhemical Stressors
ฉ ฉ
,0 ฉ ฉฆ @
e ~ee
e B ~ ,
w*
e ฉ
ฉ
ฉ
ฉ
^ ป
ฉ ^ ซ
0@
Surrounding natural spaces
Mgteprolg^ictf
Sulk Emdroffurwnt
TmHic
Rood traffic rolse
OCs
PFAiic
Metals
PhlhซUiv*
Pfvenols
ioclo-aeottornlt caplTal
Tamayo-Uria I et al. The early-life exposome: Description and patterns in six European countries.
Environment International. 2019:123:189-200.
Network
visualization of the
exposome
Proximity reflects the
within-cohort
correlation
15 groupings
illustrated by colors
20
NC STATE UNIVERSITY
College of Natural Resources
Exposomics in Children: Exposures to Chemical
and Nonchemical Stressors
Persistent Organic Pollutants
Mercury & Lead
Arsenic
Environmental Tobacco Smoke
Ultraviolet Radiation, Organophosphates,
Pestici
IT 2T " 3T f ly 2y 3y 4y Sy
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NC STATE UNIVERSITY
College of Natural Resources
PMabs -0.2j
-0.21
Exposomics in Children: SEP
I \ Greener, les;
HELIX analysis of SEP
across cities:
High between-city
variability
With gentrification of
some cities:
No clear relationship
between SEP and pollution
exposure
Not consistent among all
cities
independent effect of
less urban, less N02
(PCI: 31%)
High traffic, noise & air pollution,
less people (PC2:10%)
noisejden -o.ie 0.24 |
green_dist_inv | 0.2s 0.14
NDVI30O 017
blue_dist_inv -0.01
trafficjoad -0.16
tratfic_near -o.os
road_dist_inv -0.12
popdens -0.24
build_dens300
oonnect300 m
bus_stops300 -0.16
feat_ rich300
0.33 0.24 HL34
001 oo' 0.2a
ฐb
Ianduseshan300 ฆ
V -0,33 -<
0.28 0.22
Mm\
-012J-0.22. -0.
-0.071-015, 0
0 02 -0 02, 0.
-0.16 -0.36, 0...
0 06 -o ! 3. MS
0.09 N or, C 24
- jgg
0.09 [-0-09, 0.2!
M 1-0.32. 0. IS) REKtoOel
0.02 [-0.07. 010]
Noisy, low air pollution,
walkable. mixed use (PC3:8%)
Low traffic, high PM, natural
SDace. walkable (PC4:7%)
-0.14 -0.23, -004
-"04'|-0,11, 002
. 09 | 0.05. 0 12
-0.23 [-0.42, -0 04
-0 05 [-0,22, " "
???
0.03 -0.05, 0.10]
-0.05 -0.14, 0""
0 08i 0 W
-0.28 [-046 -0.08
. -027 [-049,-0 06
. 0.l4[0.0l 0 35
ซ 0 ,191-0 .03, 0.41
RE Model -0.01 (-0.10, 0 08]
-0.60 ' -0M ' 0.20
Greener, less urban, less N02
(PCI: 31%)
Oslo ฆ -0 341-045, -0 231
Kaunas ฆ -0 80 -0.90. -0 70
Bradford ฆ 1.34 [ 1-21, 1.48
3 PolEws ' 2 93 2 64' 323
ฐ Giojzkoa * -025 (-0.80; 0 31
SaoaOel ... -1.811-217 -144
Valencia .* 3.20 [2.75, 3.65
Heraktan -1.11 (-1.50. -0 72
Oslo ฆ
Kaunas ฆ
Bradford ฆ
Nsmcy
Pollers
Gipuzkoa . -
SaBadsll
Valencia
Heraklion
-0 091-0 16, -002
0.06 [-0.03. 0.14
0163812. SM
-0 1' 1-0 36 0.03
0 25 [ 0.06. 0.44
-0.401-0.61,-0.19
143 1". id. 1.76
0.35|0.10, 0.59
-O.05H).23. 0.12
RE Model 0,64 [-0-60. 1 68] RE Med*
0.161-0.16, 0.49
109 -4!co ' o-bo 4.00 -1.00 o.bo '100' 2.00
Noisy, low air pollution, Low traffic, high PM, natural
walkable. mixed use (PC3:8%) space, walkable (PC4:7%)
Oslo -0.04 [-0.10, 0 03
Bradford 0.19 [0.12. 026
Nancy , ซ , -0.11 (-0 30. 008
PDifera 0 34 [0.17, 051
Valencia 0.2310-04, 043
HeraWon -O.20 [-0.36. -0 04
Oslo
Kaunas
Bradford
-0 02I-0 07 0 03
ฆ" if'llll
"_^/^36|[8^Jm
~^mIVoฐ23~057
0 2310.02. 0.45
RE Model 0,03 (-0.11, 016] RE Model
0.03 1-0-23, 0.30
Family
Education
RE MoOel 0.01 [-009, 0.11]
-0.60 -0.20 0.20 0.60
High traffic, noise & air pollution,
less DeoDle (PC2:10%)
Area-level
SEP
22
Jtobinson^^O^et^L^Th^mjDan^exjsosomecjunniyDregn^nc^andJts^socioecono^
NC STATE UNIVERSITY
Exposomics in Children: Biological Age
Epigenetic age acceleration
(DNA methylation)
observed
Significant associations
with maternal tobacco
smoking during pregnancy,
indoor PM, parental
13
Horvath's All Tissue clock
4 8 12 16
OS A Mrtij ialxra age
de Prado-Bert, P et al. The early-life exposome and epigenegic age accelerati203n in
children. Environ. Intl. 2021:155:106683.
C-22
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NC STATE UNIVERSITY
Exposomics in Children: Low Birth Weight
^,NOVI_500m
NDVI 300m
Volcano clot
Greater building density
was statistically
significantly associated
Exposure family '
8uifcfc*3Density_300m^
ฎ
3
3
0-
2
CB
O
0
ฆ
T ป
*
ฆ
* A .
* t
a
~ ฆ
* * " *
ฆ
' "'T with increased low birth
ป Built Environment
Meteorology . .
~ Natural Space WGIgllt
~ Road Traffic
' Greater greenness was
statistically
significantly associated
with decreased low
-0.2 0.0 0,2
log^Fold Change)
Nieuwenhuijsen MJ etal. Influence of the urban exposome on birth weight. Environ.
Health PersDect. 2019:127:047007
24
NC STATE UNIVERSITY
Exposomics in Children: Lung Function
Decrement in
postnatal FEVi
associated with
several
stressors,
including:
- House crowding
- Commerce
around schools
Agier, L. etal. Early-life exposome and lungfunction in children in Europe: an analy2s5is of data
from the longitudinal, population-based HELIX cohort. Lancet. 2019;3:e81-92.
MEOFซ
DEHF* House crowding
v j
/ MFUMP
MECPP Ethyl-parabcn |
I-5-j Facility density* ** CBCQMiNP ^
Copper-* *
i-"
3 10-
W
ftS-
-3
* *
ป
j 'i
0 1
-kxjj (fold change]
C-23
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NC STATE UNIVERSITY
Exposure variable'
Exposomics in Children: Allergy
ExWAS multiple comparison
muJll-expcoure model
OR[95* a]' p value Frequency of selection (%) OR[95*ปa]' p value
PM*.
inverse distance to nearest road (ra~s)
oxo-MlNP (pfc/g)
Population density at home address (InfiaWtants/kin3)
Cat at home
Molybdenum iflg/L)
Cadmium (pg/10
PPOS QI&/U
BUPAQigA)
Itchy msii
Built environment
Ltfeayle
Me lab
Metals
PFASs
Traffic density on nearest road (vehicles/day) Traffic
Exposure to tobacco smoke during pregnancy (No exposure) Tobacco sncfee
Only passive exposure
MEP(ns/g)
cntWhood
NO2 (Indoors) (pg/cm3)
Total tours of Sleep (tours)
Sedentary behaviour (mm/day)
Arsenic (jig/I.)
PPOA (Jlg'T.)
PFHXS Qlg/L)
BUPA (Hg/g)
Air pollution
lifestyle
Lifestyle
Metals
PFASs
PFASS
Phenols
2.05
0.78
0-42
Prenatal
Traffic density on nearest road (V(3iicJes/dav)
inverse distance to nearest road (m~')
0.6 [0.4^.91
1.2 [1.0;1.5]
1.2 [1.0;1.41
1.3 [1.0;1.6}
0.7 [0.5;1.0]
0.9 [0.8-1.01
1.2 n.o;l.4|
0.8 [0.6;1.01
1.2 [l.l;l_31
0.02
0.02
0.04
0.02
0.03
0.03
0.03
0.01
0.007
3500 1.3 n o;isi
0.5 [0.3; 0.91
0.9 [0.5; 1.5]
0.8 [0.6; 1.0]
1.5 [1.02-3]
0.8 [0.6:1.01
1.2 [1.0;15]
1.4 [1.0:1-81
0.8 [0.6; 1.01
0.7 [0.5:1.0]
1.2 [1.0;1.4]
0.04
0.02
0.05
0.03
0.03
0.04
0.04
0.5 I0.3JK91
1.3 ii.i:i.6i
1.2 [1-0:1.41
1.3 [1.0;1.6] 0.02
0.5 10.3; 0.9] 0.01
0.9 (0.5: 1.4] 0.56
0.8 10.6; 1.0] 0.03
testing showed statistically
significant associations with:
Prenatal inverse distance to
nearest road
Prenatal phthalates
Prenatal population density
Prenatal traffic density
Childhood indoor NO2
Childhood sleep
Childhood sedentary behavior
Childhood arsenic exposure
26
Granum, B. Multiple environmental exposures in early-life and allergy-related outcomes in childhood. Environ. Intl. 2020;144:106038.
NC STATE UNIVERSITY
Exposomics in Children: BMI
d_- *86,518 CpO*^
Whole nu-tfriyl'ome Jc
StGt) Dimension reduction based
on a priori kncm-lodgi
-e-
Restricted met to tome ^ ~ 2.2S44 ( -pOV'
Step b) RcUtion b<:ซwซn restricted | V adjustment
r > methylome and BMI [ j /or ccll-iypes n
* * Associaixm tests
zBMI //
' Scmmvity analysts
I Reduced mttliyliajit '
CpGs associated d = 62CpGs
Step c)
Relation between reduced
melhylnme and BMI
Whole expowirne
=#=
Reduced espostmie
d - 216 exposures
}c
r. i\ Relation betw een reduced
otep a) cxpo,<)mc anct RM|
o
Moving to next Mcp
Looked at CpG (cytosine-
phosphate-guanine) sites that
are susceptible to methylation
Found 62 sites associated
with BMI
Then examined whole
exposome association with
BMI and narrowed it down to
2 exposures
Postnatal blood copper
- PFOS
d - 2 exposure*
C-24
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NC STATE UNIVERSITY
Exposomics in Children: Cognitive Function
Statistically significant
increase in IQwith organic
food
Small but statistically
significant decrease in IQwith
house crowding
Fast food, lead, environmental
tobacco smoke, soda,
Childhood exposome and CPM
House crowding
CL
wTj
o
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Julvez, J. et al. Early life multiple exposures and child cognitive function: A multi-centric birth
cohort study in six European countries. Environ. Poll. 2021;284:117404.
-1.0
-0.5 0.0
beta estimate
o.s
1.0
28
NC STATE UNIVERSITY
Exposomics in Children: Behavior
ADHD Index (Conners)
House oxwdtng
_
Sociafconla^
Ready made food
Caffe nc
PM2.S"in
Fastfo^g
SodBl cflgact Sweeps ;US
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for several variables, including
processed foods
Family of exposure
C-25
-------
NC STATE UNIVERSITY
IllEUMI
Exposomics Study Design Considerations
Measurement technologies
Measurement error
Multiple associations
Characterizing variability among participants, over time
Characterizing variability and uncertainty in exposure data
Confounding
Reverse causality
NC STATE UNIVERSITY
Key Challenges: Measuring Elements
of the Exposome
True exposures cannot
be completely
measured
- Bias
- Incompleteness
- Uncertainty
But, data are now easier
and cheaper to obtain
than ever
31
SirouxV, Agier L, Slama R. The exposome concept: A challenge and a potential driver for environmental health research. Eur Respir Rev. 2016;25:104-107.
Questionnaires
Residential, ป
occupational,
smoking history,
e,t
C3
GIS-based environmental model
Air pollution ^ t
Green space
-------
NC STATE UNIVERSITY
Key Challenges:
Modeling Effects of
the Exposome
More predictors mean:
- Increased bias
- Decreased specificity
- Increased false positives
- Decreased sensitivity
Positive correlation tends
to inhibit performance
Best performance: ENET
Agier Letal. A systematic comparison of linear regression-based statistical
NC STATE UNIVERSITY
Key Challenges:
Modeling Effects of the
Exposome
SES often measured with lower
spatial resolution than pollution
When using the same spatial scale
for both, associations with pollutants
often disappear while associations
with SES remain
Humphrey JL et al. Putting co-exposures on equal footing: An ecological
analysis of same-scale measures of air pollution and social factors on
cardiovascular disease in New York City. Int J Environ Res Public Health. 2019;
16:4621.
ACS 20e7^O11 Census TraSs* ""
iSI *
#5jjb
Social Deprivation Index
ACS 2007-2011 Census Tracts
0
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A'
""aCS 2007-20M Census TrKts
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C-27
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NC STATE UNIVERSITY
MATEIMT
Conclusions
Frameworks exist for studying cumulative or concurrent
ambient and nonambient exposure groupings
Validity of the results depends on choosing a model that
allows for multiple exposure effects while adjusting for
confounding
Chemical and nonchemical stressors frequently were found
to influence children's health
C-28
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Non-Chemical Stressors in
the Built Environment
AdrienneL. Hollis, PhD, JD
Hollis Environmental Consulting (HEC)
Working at the Intersection of Health, Environment and Climate
October 6, 2021
Air Quality
Accessibility
Mental Health
\
Land Use
(Housing, parks, farms, workplace, etc.)
The Built Environment
Transport Infrastructure
(roads, transit, walks, trails, etc.)
J
Safety
Motor Vehicle
Use
Physical
Activity
Water Quality
C-29
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Impact of Climate Change on Human Health
Injuries, fatalities, Asthma,
mental health impacts cardiovascular disease
Heat-related illness
and death,
cardiovascular failure
Air
Pollution
Malaria, dengue,
encephalitis, hantavirus,
Rift Valley fever,
changes Lyme disease,
/V^vjRts> \\ ,CT9M Lyme disease,
'i-ix West Nile virus
Environ-
Forced migration,
civil conflict,
mental health impacts
Increasing
Allergens Respiratory
allergies, asthma
Water and Food Water
Supply Impacts Quality Impacts
IB . . Cholera,
Malnutrition, cryptosporidiosis,
diarrheal disease Campylobacter, leptospirosis,
harmful algal blooms
Racism
C-30
-------
Environmental Racism Is Nothing New
56%
38%
Nation.
Have
seen
95%
of their claims against polluters
denied by the EPA
JET
nil
Are 1 I
more likely to
live without
potable
water and
modern
sanitation.
Race is the most
significant predictor
of a person living near
contaminated air,
water, or soil.
of the population near
toxic waste sites are
people of color.
higher
nitrogen-
dioxide
exposure.
Have
C-31
-------
https://blog.ucsusa.org/juan-declet-barreto/the-inequities-of-keepirig-cool-in-urban-heat-islands/
Difference in Environmental Risk Exposure Compared to White Americans
Percent, 2019
Traffic proximity and volume
Proximity to TSDF facilities
Proximity to RMP facilities
Proximity to major water discharger facilities
Proximity to National Priority List sites
Diesel particulate matter exposure
Air toxics respiratory hazard index
Air toxic cancer risk
Lead paint exposure
PM2.5 exposure
Ozone exposure
-21% I
0%|
-3% |
72%
87%
[30%
ฆ 42%
ฆ 22%
117%
ฆ 19%
|12%
ฆ 21%
111%
ฆ 9%
|1%
-50%
50%
150%
Source: EPA, Census and
Rhodium Group estimates
C-32
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5.5 million children under age 18 years
currently have asthma
9.8 million physician office visits with
asthma as a primary diagnosis
1.6 million emergency department visits
with asthma as a primary diagnosis
3,564 deaths from asthma
19.2 million adults aged 18 and over
currently have asthma
Black Americans are nearly 1.5 times more
likely to have asthma and Puerto Rican
Americans are 2 times more likely
Black Americans are 5 times more likely to
visit the emergency room for Asthma and 3
times more likely to die from asthma
C-33
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-------
Non-chemical Stressors from the Natural Environment
Susan Yee
Gulf Ecosystem Measurement & Modeling Division
US Environmental Protection Agency
The views expressed in this presentation are those of the authors and do not necessarily
represent the views or the policies of the U.S. Environmental Protection Agency.
I oo nof
FEfO |
FHf
Muimtors,
"Human health and well-being are inextricably
linked to the health of the natural environment
Runoff & Urbanization
Discharges
Air
Pollution
Climate
Change
Carbon Pest
Sequestration Regulation
Storm Surge
Protection
Water Green Space
Filtration
Air Pollutant
Removal
C-35
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What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Where is the ecological/human
interaction happening??
Wha attributes of the natural
environment are being used or
conferring a benefit?
How are those attributes being used?
Who is benefitting?
"[biophysical] components of nature,
directly enjoyed, consumed, or used to
yield human well-being" (Boyd ABsmhar 2007)
https://www.epa.gov/eco-research/national-ecosystem-services-classification-system-nescs-plus
https://www.epa.gov/eco-research/final-ecosystern-goods-and-services-fegs-scoping-tool
What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
"[biophysical] components of nature,
directly enjoyed, consumed, or used to
yield human well-being" (Boyd&BsnzM 2007)
What?
Air & Atmosphere
Soil & Substrate
Water
Fauna, Flora, & Fungi
Other Natural Components
Composite Attributes
Mitigation of Extreme Events
C-36
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What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Air quality
Wind strength & speed
Precipitation
Sunlight
Temperature
Air & Atmosphere
What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Soil quality
Soil quantity
Substrate quality
Substrate quantity
Soil & Substrate
C-37
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What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Water quality
Water quantity
Water movement
Water
What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Biodiversity
Edible or Medicinal
Charismatic or Culturally Important
Pollinators or Pest Regulation
Commercial or Economic Importance
Fauna, Flora, & Fungi
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What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Fuel & Fiber
Minerals & Chemicals
Other Natural Materials
Other Natural Components
What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Aesthetic Viewscapes
Sounds & Scents
Open Space
Ecological Condition
Composite Attributes
C-39
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What are the Attributes of the Natural Environment
that Affect Human Health and Well-being?
Flooding
Wildfire
Extreme Weather
Earthquakes
Documented Health
Benefits from Nature
Eco-Health Relationship
Browser
Provides scientific evidence
for linkages between human
health & ecosystem services.
httDs://www.eDa.aov/enviroatlas/enviroatlas-eco-health-relationshiD-browser
Aggression
Drylands
Anxiety
Aesthetics
Social &
Community
\ TWs
Engagement
With Nature
Respiratory
I Symptoms
Happiness
Mortality
Obesity
Longevity
Healing
C-40
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How does the Natural Environment Alter Effects
of Chemical Stressors?
Increasing or Decreasing Exposure to Chemical Stressors
Recreational waters; Flooding; Consumption of contaminated species
Buffering/filtering/absorption of pollutants; Stormwater infiltration
Decreasing Individual Vulnerability to Chemical Stressors
Buffering or mitigation of co-stressors
Recreational opportunities, clean air & water promote overall healthiness
Providing Natural Alternatives that Reduce Need for Chemicals
Biofuels; Natural pest management
Chemical Stressor impacts to Natural Environment that indirectly effect
Humans through loss of Ecosystem Services
What do we know about how Environmental
Attributes interact with Chemical Stressors?
Water
Consumption of contaminated fauna, flora, fungi
Biofuel alternatives
Natural fibers to absorb contaminants
Co-stressors (noise/smells)
Flood & Fire
!iStIf!f!ff!!!!!!!!!!!tl!!l|l!|II!II!ff!f|l1!!
s i* III IH1111111 n iI I! 11I1! 111! ฆ= I flHHr *
!lปllSll!ilH,jil!i
! 1 m
C-41
-------
Examples from San Juan, Puerto Rico
Key Question:
Could actions to restore estuary
hydrology, wetland habitat, and
greenspace lead to potential benefits for
human health and well-being?
Habitat
Loss
Climate
events
Stormwater
runoff
Sewage
discharges Flooding
Aquatic
Urbanization debris
Structured Decision Making to Frame Research
How can management of the natural environment
improve human health and well-being?
Use consideration of
natural environment to
identify viable alternative
decision-points
Communicate benefits of
environmental
management to human
health & well-being
Improve human health
and well being
Identify ecosystem
services as means
to improve health
and well-being
Statistical models & field work
to evaluate key relationships
IMPACTO
"SALUD
C-42
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Natural Environment Effects Human Weil-Being
Human Weil-Being Index to
relate Ecosystem Services to
multiple components of well-
being while accounting for
Social/Economic Services
Flood-prone areas around the
impacted canal tended to
have lower well-being
Greenspace positively
associated with higher well-
being
Linking Ecosystem Condition to Human Well-being
Ecosystem
Condition
Ecosystem
Services
Temperature
Regulation
Human
Health
Water-borne
Gl Disease
Vector-borne
Illness
Asthma
Human
Well-being
Education
Living Standards
Health
Cultural &
Leisure
Opportunities
Safety
Social Cohesion
C-43
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Linking Ecosystem Condition to Human Well-being
Ecosystem
Condition
Ecosystem
Services
Human
Health
Temperature
Regulation
b
Water-borne
Gl Disease
Vector-borne
Illness
Asthma
Human
Well-being
Education
Living Standards
Health
Cultural &
Leisure
Opportunities
Safety
Social Cohesion
Myers et al, 2013
Mold and Asthma Waterborne Gl Disease
How do flooding events & building materials Does rainwater retention by urban greenspaces
impact mold and bacterial populations in homes? and soils help mitigate water-borne Gl diseases?
Connection to
Nature
water-borne
Gl Disease
I Ecosystem
Condition
Education
Living Standards
Temperature
Regulation
Flood
Protection
C-44
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Vector-borne Illness
Key Question:
Cart wetland ecosystem services help
mitigate mosquito-borne illnesses?
Nature
Living Standards
Safety
Social Cohesion
Ecosystem
Condition
f \
Ecosystem
Services
Human Health
Human
Well-being
Hypothesized Relationships
High nitrogen may boost mosquito populations
Wetland habitat may favor bio-control
High temperatures may increase mosquito
biting, oviposition rate, viral load
Floods may increase larval habitat availability
De Jesus-Crespo et al. 2017. Wetlands.
Vector-borne Illness
Key Question:
Can wetland ecosystem services help
mitigate mosquito-borne illnesses?
Connection to
Nature
Education
Health
Social Cohesion
Insulating Layers may Alter Ecosystem Effects
Built Infrastructure
Waste Management
Population Density of Teenagers
Wealth & Housing Quality
De Jesus-Crespo et al. 2017. Wetlands.
Ecosystem
Services
Ecosystem
Condition
Human Health
C-45
-------
Vector-borne Illness
Genera! Linear Models to relate Metrics of Wetland Habitat, Ecosystem
Services, and Insulating Layers to Dengue Prevalence
Dengue prevalence negatively associated
with woody wetlands and salinity; positively
associated with flood zones, air
temperature, water nitrogen
Relationships stronger (e.g. ecosystem
services benefits stronger) neighborhoods
with low income or high density of teenagers
Positive benefits of wetlands primarily
related to temperature regulation
De Jesus-Crespo et al. 2017. Wetlands.
Vector-borne Illness
Related field study establishes a pathway
by which nitrogen in the environment
may influence viral capacity in mosquitos
Yee et al. 2017. EcoHealth
C-46
-------
Summary
Decision context and local community concerns
can help prioritize stressors for which research
needs are highest
Managing the natural environment can benefit
human health & well-being
Natural environment can provide sustainable
alternatives to chemical use
Insulating layers from the social/built
environment can exacerbate or buffer effects of
the natural environment
Acknowledgments
San Juan, Puerto Rico
ENLACE
Evelyn Huertas (US EPA)
San Juan Bay Estuary Program
Gastrointestinal Illness
Rebeca de Jesus Crespo (LSU)
Rich Fulford (US EPA)
Laura Jackson (US EPA)
Mark Myer (US EPA)
Lucas Neas (US EPA)
Jianyong Wu (US EPA)
FEMA of Puerto Rico
Vector-borne Illness
Rebeca de Jesus Crespo (LSU)
Pablo Mendez Lazaro (University of Puerto Rico)
Autumn Oczkowski (US EPA)
Donald Yee (University of Southern Mississippi)
Fengwei Bai (University of Southern Mississippi)
Stephanie Friedman (US EPA)
Roberto Barrera (CDC)
Mold and Asthma Linda Harwe||
Doris Betancourt (US EPA)
Steve Vesper (US EPA)
Benjamin Bolanos (University of Puerto Rico)
Filipa Godoy-Vitorino (Interamerican University, PR)
Human Well-being
Elizabeth Paulukonis (US EPA)
Jessica Orlando (US EPA)
Lisa Smith (US EPA)
Kyle Buck (US EPA)
Linda Harwell (US EPA)
Carbon, Nitrogen, & Flooding
Cathy Wigand (US EPA)
Rose Martin (US EPA)
Autumn Oczkowski (US EPA)
Alana Hanson (US EPA)
Steve Balogh (US EPA)
Justin Bousquin (US EPA)
Ben Branoff (US EPA)
K'M
tut"
NESCSPIus, FEGS Scoping Tool, EcoHealth Browser
Matt Harwell (US EPA)
Leah Sharpe (US EPA)
Tammy Newcomer-Johnson (US EPA)
Laura Jackson (US EPA)
Marc Russell (US EPA)
C-47
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References
Betancourt, D., T. Dean, AND E. Huertas. An EPA pilot study characterizing fungal and bacterial populations
at homes after flooding events at the Martin Pena Channel Community. Microbiology of the Built
Environment, Lloyd Harbor, New York, November 03 - 06, 2019..
https://cfpub.epa.gov/si/si public record report.cfm?dirEntryld=348231
De Jesus Crespo, R., P. Mendez-Lazaro, S.H. Yee. 2018. Linking wetland ecosystem services to vector borne
disease: Dengue fever in the San Juan Bay Estuary, Puerto Rico. Wetlands
https://doi.org/10.1007/sl3157-017-099Q-5
De Jesus Crespo, R., J. Wu, M. Myer, S. Yee, R. Fulford. 2019. Flood protection ecosystem services in the coast
of Puerto Rico: Associations between extreme weather, flood hazard mitigation, and gastrointestinal illness.
Science of the Total Environment. 676:343-355. h
Myers SS, Gaffikin L, Golden CD, Ostfeld RS, Redford KH, Ricketts TH et al (2013) Human health impacts of
ecosystem alteration. Proceedings of the National Academy of Sciences 110(47):18753-18760.
https://doi.org/10.1073/pnas.1218656110
Yee, S., J. Bousquin, R. Bruins, T.J. Canfield, T.H. DeWitt, R. de Jesus-Crespo, B. Dyson, R. Fulford, M. Harwell,
J. Hoffman, C.J. Littles, J.M. Johnston, R.B. McKane, L. Green, M. Russell, L. Sharpe, N. Seeteram, A. Tashie,
and K. Williams. 2017. Practical Strategies for Integrating Final Ecosystem Goods and Services into
C-48
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THE GEORGE
WASHINGTON
U N IVERSITY
WASHINGTON, DC
Integrating Intersectfonality into the Exposome:
New Directions In Environmental Justice
Ami R. Zota, ScD, MS
Director of ARISE-EJ lab
Associate Professor
Department of Environmental and Occupational Health
George Washington University Milken Institute School of Public Health
Founding Director, Agents of Change in Environmental Justice
October 6, 2021
Long history of Black, Indigenous and Brown communities fighting
for healthy environments where they live, work, play, and pray
C-49
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Racial/ethnic and socioeconomic inequities in exposures persist
Air pollution
Polychlorinated Lead
Biphenyl
Compounds
Perfluorinated
Alkyl Substances
Phthalates
and
Parabens
Flame
retardants
3
Data: Nina Martin and Renee Montagne. "Nothing Protects Black Women
from Dying in Pregnancy and Childbirth." ProPubllca. Dec 17,2017.
243%
C-50
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Intersectionality Exposome
JL
Environmental Justice
ir
Zota and VanNoy 2021
C-51
-------
enter
systematically
marginalized
populations
Build transdisciplinary collaborations
Reexamine approach to
health research
Integrate social
and structural
determinants
:uantify contributions of
environmental factors to
racial health disparities
Prioritize
community
engagement
C-52
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Black and Latinx population use more products across multiple categories
You need a miracle!
Hair products
Dodson et al., 2021
Edwards et al., unpublished
Zota and Shamasunder 2018
Sprint
Welcome to Taking Stock
TAKING STOGKj
The Taking Stock study is a community-
based research project to enhance what is
known about the products women use
every day and how these products
contribute to disparities in health.
To begin, press Continue below.
Add to My Produ...
Brand and Product name: mrs
Meyer's clean day dish soap
Cleaning
Dish liquid
Is this product labeled as "Fragrance-free"
or"Unscented"? *
Done
Cleaning wipes (e.g. Clorox
Dish liquid
sinfectan
(used i
Back Label
Is all the information on the label shown in the
frame? Is the text in focus and readable?
EFFECTIVE, TRUSTED FORmuu,
Wink:' Mate Wtthoai
turn tauns nuoinis nuuius i pitulsq
*kU KUDU
MTIFICUl CUM
Take Again
Skin lightening
creams
Fragranced products,
vaginal deodorants
Cosmetics
C-53
-------
Cleaning
Cosmetics
Feminine Care1
Hair Products
Personal Care2
Women used an
average of
products daily
Pest Control
0 2 4 6
Average number of products used daily
Race/ethnicity Black ฆ Latinx
Unpublished data from the Taking Stock Study
California Breast Cancer Research Program (No 23UB-6511)
1 Feminine care products include both menstrual products as well as vaginal washes and wipes
2 Persona I care products include bath and body products, oral care, and deodorants
Black
Latinx
- ^ 99 Cent Store
The most popular
|j- Amazon (Online)
retailers among
J - Bath and Body Works
women living in
- Beauty supply store
South Los Angeles
Costco
were Target and 99
J- CVS
Cents Store. *
Given to me/Gift
Ralphs
Rite Aid
>60% of Black
Sephora
wnmpn rprpix/pH
Target
V V w 1 1 1 vฆ 1 1 1 vฆ vฆ 1 V vฆ
products as gifts
Trader Joes
1
J- Ulta
Walmart
80 60
40 20 0
Percent of women
20 40 60 80
Unpublished data from the Taking Stock Study
C-54
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Proportion of participants who use douches
Education matters: Vaginal douche use
is highest among Black women without
college education
Black White Latinx Other
High School or less
Black White Latinx Other
Some college or more
'f
FORGE
tin
|TAKINGSTQCKSJUOY.ORB|
Zota et al.,
unpublished
Center
systematically
marginalized
populations
Build transdisciplinary collaborations
txpai
xposor
Reexamine approach to
health research
Quantify contribution
environmental factors to
racial health disparities
Prioritize
community
engagement
C-55
-------
Environmental Injustice of Beauty: An example
Type of
Less
Product use
Chemical
Potential adverse
discrimination
advantaged
exposures
outcomes
populations
Natural hair
African
Chemical hair
Parabens,
Uterine fibroids,
discrimination
American
straighteners
phthalates,
breast cancer
women
siloxanes
Zota and Shamasunder, 2018
Perceptions about hair and use of chemical straightening
products (CSPs)
Opinion of Straight Hair: Self vs. Others
M Self
H Others
I ll II
Make women
look more
beautiful
Make women
look more
professional
Make women
look younger
! p<0.05
Other's Opinions of Hairstyle and
Personal CSP Use
H Straight Hair
Curly Hair or No preference
w
<ง 8) 40
.9- o
o
-------
Ask innovative questions to advance health equity
Center
systematically
marginalized
populations
tegrate social
and structural
erminants
Prioritize
community
engagement
Build transdisciplinary collaborations
Advancing change requires more than good science
Policy
Communication Training next gen leaders
C-57
-------
Agents of Change in
cultivate new Environmental Justice
environmental
Inject new ideas
in environmental
justice leaders
health and
climate fields
To empower emerging leaders from
historically excluded backgrounds in
science to reimagine solutions for a
just and healtj^ planet
Increase
environmental
justice literacy
among STEM
students
Make scientific
information
more accessible
to marginalized
communities
A joint initiative between GW Milken School of Public Health and Environmental Health News
ellows at a Glance
31 doctoral students, postdocs, and early career scientists
From marginalized backgrounds including first-
generation college graduates; individuals from
communities of color; and individuals with disabilities.
Muldisciplinary scholars
Environmental health
Epidemiology
ป Community health
ป Chemistry
Urban planning
Medicine
Sociology
Engineering
Education
Ecology
Nutrition
ป Microbiology
C-58
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Early Signs of Impact
Wide update of our original content
24 essays published on EHN
1,220,000 reads in English and Spanish
23 podcasts episodes
10,000 downloads/listens
Fellow gaining visibility as emerging leaders
Transitioning to tenure-track positions
Giving invited talks at funding agencies,
universities, and community groups
Publishing opinion pieces in popular media
Krystal Vasquez
Environmental injustice and
disability: Where is the research?
agentsofchangeinej.org
The intersectionalitv exposome will move us towards
environmental justice by advancing innovation in:
Research Policy Training
C-59
-------
Acknowledgements
Co-Investigators/Collaborators
FORGE Study: Drs, Gaby Moawad, Cherie Marfori, Andrea Raccarelli, Shuang Wang, Antonia Calafat, Lisa
Bowleg, Tamara Taggart, Nadia Khati
TAKING STOCK: Dr. Bhavna Shamasunder, Jan Flint, Sandy Navarro, Dr, Robin Dodson
Beauty Inside and Out: Lubna Ahmed, Leslie Martinez, Dr. Robert Dubrow, Marissa Chan, Taylor Morton
Agents of Change: Brian Bienkowski, Douglas Fischer, Gwen Ranniger, Dr. Yoshi Ornelas Van Home
GW Milken School of Public Health Research Team
Brenda Trejo, Roshni Rangaswamy, Samar Ahmad, MyDzung Chu, Lariah Edwards, Erin Gomez, Toni Jurious,
Angela Kim, Olivia Wilson [Former: Ruth Geller, Susanna Mitro, Brianna VanNoy, Darah Wright, Tyiesha Johnson,
Angela Stoer, Dan Dinh, Raya Hudhud, Sydney Young, Tahera Alnaseri]
Funding:
National Institute of Health (NIEHS R00ES019881 R01ES031065; NICHD R21HD096248)
National Center for Advancing Translational Sciences (UL1TR001876, KL.2TR001877)
California Breast Cancer Research Program (No 23UB-6511)
GW Milken School of Public Health Pilot Awards
GW Cancer Center, GW OVPR Cross-Disciplinary Fund, GW/Children's National CTSI
Forsythia Foundation, Marisla Foundation, Passport Foundation, Rachel's Network, Broad Reach, Beautycounter
Twitter: @amizota
ฆPasstheCROWN
The CROWN Act
Creating a
Respectful and
Open
World for
Natural Hair.
thecrovnact.com
Mural by Caridice Taylor,
Washington DC
C-60
-------
Vaginal douching use contributes to racial
differences in phthalate exposure
Vaginal Douches
Feminine Spray
Feminine Powder
Wipes/Towelettes
Tampons
150% higher
MEP levels
300
Black
women
250
Si 200
ฆ
ฆ- 150
-------
Ip
INDIANA UNIVERSITY
BLOOMINGTON
Water Infrastructure to Improve Childhood Health
and Decrease Childhood Lead Exposure
Jackie MacDonald Gibson, PhD
Professor and Chair
Department of Environmental and Occupational Health
Indiana University, Bloomington
October 5, 2021
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Outline
* Research motivation and objectives
o Racial "underbounding" and exclusion from municipal water
service as nonchemical stressors
o Effects of these stressors on children's health and wellbeing
* Methods
o Total environment framework
o Data collection and analysis approach
* Results
o Effects on early-childhood blood Pb
o Effects on risks for adolescent delinquent behavior
* Potential solutions
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Municipal "Underbounding" as a
Nonchemical Stressor
"Selectively expanding] the corporate
boundary to exclude blacks."
Charles Aiken, "Race as a Factor in Municipal Underbounding"
Annals of the Association of Amer Geographers, 1987
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Underbounding Example
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Black Communit es at City Fr nge Are
More Likely to Be Excluded from Service
CD
Q.
O
(L 9 _
0.0 0.2 0.4 0.6 0.8 1.0
Proportion of Census Block Population That Is African American
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Underbounding and Water Service
Exclusion Create Economic Stress
"[We spend] 15 bucks a week of doing laundry [even
though] we own a perfectly functioning washing machine
that we can't use. We spend probab
on paper plates and plastic ut
"They went 832 feet down for my well but that cost me
$10,000 and then for them to do the hookup with all this
technology that they have to use and going down 700
feet with the pipes and the wat
$10,000."
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Additional Stress Arises from Effects
on Activities of Daily Living
Foregone
Activities
Caused by
Insufficient
Water Supply
Toilets
Showers
Laundry
Drinking
Dishes
Cooking
Bottled Water
Conservation (Other)
0
8
2 4 6 8
Number of Respondents (n=9)
10
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Lead (Pb) Exposure Risks May Be
Comparable to Flint in Water Crisis
.Q
Q.
Q.
LO
A
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CO
(D
35
30
25
20
15
^ 10
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t 5
Q)
"co
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(D
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o
X
0
ฆ % of Houses > 15 ppb in Water
% of Children with Elevated Blood Lead
i&
Ward Ward Ward Ward Ward Ward Ward Ward 6
Ward 5
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CO
(D
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o
o
00
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0)
CO
>
0)
LU
c
(D
O
Peri-Urban Wake County
SOURCE: Stillo FJ, MacDonald Gibson J. 2018. Racial disparities in access to municipal water supplies in the
American South: impacts on children's health. Int Public Heal J 10.
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Research Questions
1. How does lack of community water servicea
nonchemical stressor-affect children's health?
o Early-life Pb exposure
o Adolescent behavioral outcomes
2. What are some possible solutions?
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Research Questions
1. How does lack of community water servicea
nonchemical stressor-affect children's health?
o Early-life Pb exposure
o Adolescent behavioral outcomes
2. What are some possible solutions?
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Proposed Causal Model
Race
Lack of
municipal
water
Income
Reliance
on private
well
i
Location of
home
Age of
home
Corrosion
control
i
Value of
home
Lead in
paint, dust,
soil
Lead in
tap water
Child's age
Lead in
blood
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Methods: Question 1Water
Source Effects on Children's
Health
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Study Area: Wake County, NC
IT
P
~r
Orange
r->
>.y\.
.,'S
I
_ Durham, NC
Durham .....
r
Granville u
i
ฃ#* ซ ' iฃ V\
i'. ~* V
Louisburg, NC
Franklin
Water Source
Year 2017
~v
J:/
V7
> >
ti/ ^i* ;
Archer Lodge-Clayton
",s $ ... i
Lee
City Water
Private Well Water
City Boundaries
r j County Boundaries
Harnett
-i
12 r \.{ ซS
Mileshfield.'NC
CLi
Wayne
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Children's Outcomes (n=59,483)
Outcome
Data Source
Early-life blood Pb
NC Childhood Lead
Poisoning Prevention
Program
Teenage juvenile delinquency
NC Department of Public
Safety
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Research Design Guided by Total
Environment Framework
Policies and
Programs:
Pb control
policies
Children's Health
Effects:
Blood Pb
Delinquency rates
Educational
outcomes
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Curated Data Set (n=59,483) Includes
Multiple Nonchemical Stressors
Total Environment
Measures
Component
Built environment
Age of housing
Access to community water service
Social environment
Family income
Neighborhood demographics
Activities and behaviors
Residential mobility
Policies and programs
Pb control policies
Inherent characteristics
Sex
Age
Race/ethnicity
Natural environment
Season
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Used Regression to Estimate Water
Source Effect on Early-Life Blood Pb
T
Race
Income
Location of
home
Age of
home
Lack of
municipal
water
Reliance
on private
well
Corrosion
control
Value of
home
Lead in
paint, dust,
soil
Lead in
tap water
Child's age
Lead in
blood
= *+ + *- &./0123 43!!() + *56173( + *89:7";3(
+ *<=">?3 @#3f -I
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Pb Effects on Teen Behavior Estimated
via Two-Stage Least-Squares Regression
Lack of
municipal
water
Location of
~
home
Value of
' home
/
Age of
home
Lead in
paint, dust,
soil
Reliance
on private
well
Corrosion
control
Child's age
Lead in
tap water
Lead in
blood
Juvenile
record
!"#
(t
$(&'!()*+'),).
- $(&'!()*+'),)
=2(!"#(4j35$6.)) + B;:
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Results: Question 1Water
Source Effects on Children's
Health
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Children Lacking Community Water
Services Have Higher Blood Pb
Water source
City water (n=43,982)
Private well water (n=7,709)
0.25 0.5 0.75 1 1.25 1.5 1.75
Fractional Change in Blood Lead
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Many Other Nonchemical Stressors Also
Influence Early-Life Blood Pb
Water source
City water (n=43,982)
Private well water (n=7,709)
Age (months)
0-8 (n=478)
9-14 (n=39,688)
15-19 (n=3,844)
20-29 (n=8,603)
> 30 (n=6,870)
Year house was built
Before 1950 (n=3,401)
1950-1977 (n=12,102)
1978-1987 (n=7,874)
1988-1997 (n=9,908)
1998-2002 (n=10,003)
2003-2007 (10,330)
2008 or later (n=4,473)
Black population fraction
Home value (natural log)
Blood draw type
Venous (n=50,876)
Capillary (n=5,446)
Median income (natural log)
Extraterritorial jurisdiction (n=3,148)
Biological sex
Female (n=28,752)
Male (n=29,578)
Season
Winter (n=13,658)
Spring (n=14,942)
Summer (n=15,473)
Fall (n=15,410)
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Increased Blood Pb Contributes to
Increased Juvenile Delinquency Risk
Variable
Model 1: Full Data Set
Model 2: Quasi-
(n=13,580)a
Experimental Matched
Data Set (n=3,898)a b
Any Delinquency
Blood Pb (natural log) predicted from water source
and other variables (stage 1 model, Table 2)
3.27***
6.35***
Age indicator
3.05***
2.21
Male sex at birth (reference=female)
2.51***
3.44***
Black race (reference=all other)
2.78***
4.01***
Census block group median income (natural log) at
0.437***
0.284***
age 14
Census block group % Black at age 14
1.19
0.480
Serious Delinquency
Blood Pb (natural log) predicted from water source
and other variables (stage 1 model, Table 2)
4.39***
23.4***
Age indicator
2.36*
2.88
Male sex at birth (reference=female)
3.33***
2.86**
Black race (reference=all other)
3.05***
2.82**
Census block group median income (natural log) at
0.431***
0.295**
age 14
Census block group % Black at age 14
1.29
0.419
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Increased Blood Pb Contributes to
Increased Risk of Any Delinquency
Variable
Model 1:
Full Data Set
(n=13,580)a
Model 2:
Quasi-
Experimental
(n=3,898)ab
Blood Pb predicted from water
source
3 27***
6.35***
Age indicator
3.05***
2.21
Male sex at birth (reference=female)
2 51 ***
3 44***
Black race (reference=all other)
2 78***
4 Q-| ***
Block group median income, age 14
0.437***
0.284***
Block group % Black, age 14
1.19
0.480
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Risk of Serious Delinquency Also
Increased
Variable
Model 1:
Full Data Set
(n=13,580)a
Model 2:
Quasi-
Experimental
(n=3,898)ab
Blood Pb predicted from water
source
4.39***
23 4*"**
Age indicator
2.36*
2.88
Male sex at birth (reference=female)
3.33***
2.86**
Black race (reference=all other)
3.05***
2.82**
Block group median income, age 14
0.431***
0.295**
Block group % Black, age 14
1.29
0.419
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Providing Community Water Service
Expected to Decrease Delinquency
Any Complaint, Boys
14.0 14.5 15.0 15.5 16.0
Age
Black, well
water
Black,
community
water
All other
races, well
water
All other
races,
community
water
-------
Question 2: Potential Solutions
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Potential Solutions
* Educate homeowners to test their well water for Pb
* Encourage use of water filters when Pb is high
* Extend community water service
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We Designed a Postcard to Promote
Water Testing
jjj UNC
Time to Test Your Well!
You cannot see lead in well water.
You cannot smell arsenic in well water.
You cannot taste bacteria In well water.
Has it been more than a year since
you tested your well water?
It's time!
4
Fof any question* about ttm matter, contact Or. JacซMttn* MacDonaM GiMon
at gllHngปwซttw&ซr#unc.*4u
Be confident your water quality Is good.
Call today: 919-707-5910
It's Easy!
1. FOLLOW the rcvommended trying uhcdulr
2. TEST through you* rooaty hrakli drjuitmntt
or a fcxc-crrtihcd lib.
InofgiMo skH ai
ซftrpnin tacta at
, PtSTICIOCS and V
Find a County Hoalth Deportment or State-Certified Lab
VISIT
http://epi .publichealth.nc.gov/oee/wellwater/ howtotest.html
OR CALL
919-707-5910
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Randomized Trial Showed Postcard
Worked Only with Free Test Offer
Table 5. Logistic regression model for testing whether a combination of risk
information and free test offer influences water testing*
Variable
Odds of Water Test
P
Baseline**
0.038
<0.001
Intervention
Free water test postcard
1.16
0.82
Risk communication postcard
0.128
0.071
Risk communication with free test postcard
13.0
0.046
Remember receiving a postcard about well water
testing
12.1
<0.001
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We Tested Low-Cost Under-S nk Water
Filters (n=17 Homes)
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The Filters Effectively Removed Pb
1-30
15
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3
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2
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c
0)
o
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o
.a
Q.
10-
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5 -
<9
o
0-
I
Inf
Eff
Days of operation
31-60
CP
o
T
"Inf"
i
Eff.
61-90
3:
_ .b
91-120
Co
o
o
Inf. Eff. Inf.
Sample location
1
Eff.
121-150
ฐo
I
Inf.
i
Eff
211-250
ฃl.
TT
O
I-
"inT
15 ppb
1 ppb
Eff.
Filter influent
Filter efffluent
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We Tested Water Before and After
Community Serv ce in Five Homes
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Pb Declined Below Action Level in the
Two Homes with Pb>15 ppb
Time Since Water Service Connection (Days)
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Pb Also Declined in the Three Houses
with Pb<15 ppb
Time Since Water Service Connection (Days)
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Summary
Nonchemical stressors in early life affect adolescent
health
o Exclusion from municipal water service increases early-life
exposure to Pb in drinking water
o This exposure increases adolescent delinquency risk
* Solutions exist
o Educate homeowners to test, treat their water
- Education intervention worked only when test was free
- Filters require frequent replacement and maintenance
o Extend community water service
- Maintenance by professional engineers provides stronger
performance assurance
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Thank you!
* EPA STAR Program
o Dr. Intaek Hahn
* Co-Investigators
o John MacDonald, Phil Cook, Mike Fisher, Wandi Bruine de
Bruin, Keith Levine, James Harrington
* Students
o Dr. Frank Stillo, Dr. Riley Mulhern, Erica Wood, Sydney
Lockhart, April Desclos, Ally Clonch, many others
* Community Members
o Robert and Vanessa Lassiter, research participants
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Thank you (continued)!
* NC Division of Public Health
o Ed Norman, Tina Hand, Melanie Napier
* NC Department of Public Safety
o Megan Howell, Phil Maychek
* NC Education Research Data Center
o Clara Muschkin, Kara Bonneau
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MacDonald Gibson Group
Relevant Publications
MacDonald Gibson, Jacqueline, Frank Stillo III, Erica Wood, Sydney Lockhart, and Wandi Bruine de
Bruine. 2021. Private well testing in peri-urban African-American communities lacking access to
regulated municipal drinking water: a mental models ap-proach to risk communication. Risk Analysis.
DOI: 10.1111/risa.13799.
Mulhern, R., B. Grubbs, K. Gray, and J. MacDonald Gibson. 2021. User experience of point-of-use water
treatment for private wells in North Carolina: Implications for outreach and well stewardship. Science
of the Total Environment 806(1): 150448. DOI: doi.org/10.1016/j.scitotenv.2021.150448
Mulhern, R., and J. MacDonald Gibson. 2020. Under-sink activated carbon water filters effectively
remove lead from private well water for over six months. Water 12:3584. DOI:
doi:10.3390/w12123584
MacDonald Gibson, J., M. Fisher, A. Clonch, John M. MacDonald, and P. Cook. 2020. Children drinking
private well water have higher blood lead than those with city water. Proceedings of the National
Academy of Sciences of the United States of America 117(29):16898-16907. DOI:
10.1073/pnas.2002729117
Lockhart, S., E. Wood, and J. MacDonald Gibson. 2020. Impacts of exclusion from municipal water
service on water availability: a case study. NEW SOLUTIONS: A Journal of Environmental and
Occupational Health Policy 30(2):127-137. DOI: 10.1177/1048291120932913
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MacDonald Gibson Group
Relevant Publications (continued)
Fizer, C. M., W. Bruine de Bruin, F. J. Stillo, and J. MacDonald Gibson. 2018. Barri-ers to managing
private wells and septic systems in underserved communities: mental models of homeowner decision
making. Journal of Environmental Health 8(5):8-15.Leker, H., and J. MacDonald Gibson. 2018.
Relationship between race and community water and sewer service in North Carolina, USA. PLoS
O/VE13(3):e0193225 (pp. 1-19). DOI: 10.1371/journal.pone.0193225.
Stillo, F., and J. MacDonald Gibson. 2018. Racial disparities in access to municipal water supplies in the
American South: Impacts on children's health. International Public Health Journal 10(3):309-323.
Stillo, F., and Jacqueline MacDonald Gibson. "Exposure to Contaminated Drinking Water and Health
Disparities in North Carolina." American Journal of Public Health 107.1 (2017): 180-185.
DeFelice, Nicholas B., Jill E. Johnston, and Jacqueline MacDonald Gibson. "Reducing Emergency
Department Visits for Acute Gastrointestinal Illnesses in North Carolina (USA) by Extending
Community Water Service." Environmental Health Perspectives 24.10 (2016): 1583-1591.
Naman, Julia Marie, and Jacqueline MacDonald Gibson. "Disparities in Water and Sewer Services in
North Carolina: An Analysis of the Decision-Making Process." American Journal of Public Health
105.10 (2015): e1-e7.
MacDonald Gibson, J. et al. "Racial Disparities in Access to Community Water Supply Service in Wake
County, North Carolina." Frontiers in Public Health Services and Systems Research 3.3 (2014):
Article 6.
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Selected Additional References
Aiken, CS. "Race as a Factor in Municipal Underbounding." Annals of the Association of American
Geographers July 2013 (1987): 37-41.
Gilbert, Peter. "The State of Exclusion: An Empirical Analysis of the Legacy of Segregated Communities in
North Carolina." UNC Center for Civil Rights. 2013.
Heaney, Christopher et al. "Use of Community-Owned and -Managed Research to Assess the
Vulnerability of Water and Sewer Services in Marginalized and Underserved Environmental Justice
Communities." Journal of environmental health 74.1 (2011): 8-17.
Heaney, Christopher D et al. "Public Infrastructure Disparities and the Microbiological and Chemical
Safety of Drinking and Surface Water Supplies in a Community Bordering a Landfill." Journal of
Environmental Health 75.10 (2013): 24-36.
Johnson, James H. et al. "Racial Apartheid in a Small North Carolina Town." The Review of Black Political
Economy 31.4 (2004): 89-107.
Joyner, Ann Moss, and Carolyn J Christman. Segregation in the Modern South: A Case Study of
Southern Moore County. Cedar Grove Institute for Sustainable Communities. 2005.
Lichter, Daniel T. etal. "Municipal Underbounding: Annexation and Racial Exclusion in Small Southern
Towns." Rural Sociology 72.1 (2007): 47-68.
Marsh, Ben, Allan M. Parnell, and Ann Moss Joyner. "Institutionalization of Racial Inequality in Local
Political Geographies." Urban Geography 31.5 (2013): 691-709.
Wilson, Sacoby M. et al. "Built Environment Issues in Unserved and Underserved African-American
Neighborhoods in North Carolina." Environmental Justice 1.2 (2008): 63-72.
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