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Current Issue

Volume 131, Issue No. 1 January/February 2016
Current Issue
Full Contents | Past Issues
ISSN 0033-3549

January/February 2016
Public Health Reports

A Message from the Editor
Frederic E. Shaw, MD, JD

Letter to the Editor
Shannon M. Farley, DrPH / Kevin R. Schroth, JD / Christine Johnson Curtis, MBA / Sonia Angell, MD, MPH

Executive Perspective: HRSA’s Transformation of Public Health Training
Mary Beth Bigley, DrPH, MSN, APRN, FAAN

The Shift to High-Impact HIV Prevention by Health Departments in the United States
David W. Purcell, JD, PhD / Eugene McCray, MD / Jonathan Mermin, MD, MPH

A Call for Greater Consideration for the Role of Vaccines in National Strategies to Combat Antibiotic-Resistant Bacteria: Recommendations from the National Vaccine Advisory Committee
National Vaccine Advisory Committee

Overcoming Barriers to Low HPV Vaccine Uptake in the United States: Recommendations from the National Vaccine Advisory Committee
National Vaccine Advisory Committee

Hepatitis A Infections Among Food Handlers in the United States, 1993–2011
Umid M. Sharapov, MD, MSc / Karine Kentenyants, MD, MPH / Justina Groeger, MD, MPH / Henry Roberts, PhD / Scott D. Holmberg, MD, MPH / Melissa G. Collier, MD, MPH

Using a Handheld Device for Patient Data Collection: A Pilot for Medical Countermeasures Surveillance
Matthew F. Daley, MD / Kristin Goddard, MPH / Melissa McClung, MSPH / Arthur Davidson, MD, MSPH / Gretchen Weiss, MPH / Ted Palen, MD, PhD, MSPH / Carsie Nyirenda, MPH / Richard Platt, MD, MSc / Brooke Courtney, JD, MPH / Marsha E. Reichman, PhD

A Tool for Providing Data on Small Areas: Development of Neighborhood Profiles for Santa Clara County, California, 2014
Whitney L. Webber, MS / Pamela Stoddard, PhD / Brianna van Erp, MPH, MPP / Mandeep Baath, MPH / Greg Bazhaw, MRCP / Kate Kelsey, MPH / Douglas Schenk, MA / Roshini Shah, MPH / Bill Shoe, MCRP / Anandi Sujeer, MPH

Integrating Public Health and Deliberative Public Bioethics: Lessons from the Human Genome Project Ethical, Legal, and Social Implications Program
Karen Meagher, PhD / Lisa M. Lee, PhD, MA, MS

Shifting Resources and Focus to Meet the Goals of the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010–2013
Stephen A. Flores, PhD / David W. Purcell, JD, PhD / Holly H. Fisher, PhD / Lisa Belcher, PhD / James W. Carey, PhD, MPH, MA / Cari Courtenay-Quirk, PhD / Erica Dunbar, MPH / Agatha N. Eke, PhD, MEd / Carla Galindo, MPH, CHES / Marlene Glassman, PhD, MSW / Andrew D. Margolis, MPH / Mary Spink Newman, PhD / Cynthia Prather, PhD / Dale Stratford, PhD / Raekiela D. Taylor, MPH / Jonathan Mermin, MD, MPH / ECHPP Project Team

A Critical Assessment of Officially Reported Chagas Disease Surveillance Data in Mexico
Ellen M. Shelley, MS / Rodolfo Acuna-Soto, MD, PhD / Kacey C. Ernst, PhD / Charles R. Sterling, PhD / Heidi E. Brown, PhD, MPH

Evaluation Framework for HIV Prevention and Care Activities in the Enhanced Comprehensive HIV Prevention Planning Project, 2010–2013
Holly H. Fisher, PhD / Tamika Hoyte, MPH / Stephen A. Flores, PhD / David W. Purcell, JD, PhD / Erica Dunbar, MPH / Dale Stratford, PhD

Systematic Review and Meta-Analysis of Inhaled Toxicants from Waterpipe and Cigarette Smoking
Brian A. Primack, MD, PhD / Mary V. Carroll, RN, BSN / Patricia M. Weiss, MLIS / Alan L. Shinhadeh, ScD / Ariel Shensa, MA / Steven T. Farley, BS / Michael J. Fine, MD, MSc / Thomas Eissenberg, PhD / Smita Nayak, MD

Associations Between Social Determinants of Health and Pregnancy Among Young People: A Systematic Review of Research Published During the Past 25 Years
Sarah B. Maness, PhD, MPH / Eric R. Buhi, PhD, MPH

Exposure to Suicide in the Community: Prevalence and Correlates in One U.S. State
Julie Cerel, PhD / Myfanwy Maple, PhD / Judy van de Venne, PhD / Melinda Moore, PhD / Chris Flaherty, PhD / Margaret Brown, MPH

Needs Assessment for Patients with Sickle Cell Disease in South Carolina, 2012
Alyssa M. Schlenz, PhD / Andrea D. Boan, Phd, MSCR / Daniel T. Lackland, DrPH / Robert J. Adams, MS, MS / Julie Kanter, MD

Evaluating Shared Laboratory Services: Detecting Mycobacterium Tuberculosis Complex and Drug Resistance Using Molecular and Culture-Based Methods
Julie Tans-Kersten, MS, BS-MT(ASCP) / Shou-Yean Grace Lin, MS / Edward Desmond, PhD / David Warshauer, PhD

Evaluating Early Case Capture of Pediatric Cancers in Seven Central Cancer Registries in the United States, 2013
Mary Puckett, PhD / Antonio Neri, MD, MPH / Elizabeth Rohan, PhD, MSW / Castine Clerkin, MS, CTR / J. Michael Underwood, PhD / A. Blythe Ryerson, PhD, MPH / Sherri L. Stewart, PhD

HIV Testing in Publicly Funded Settings, National Health Interview Survey, 2003–2010
Cheryl Tan, MPH / Michelle Van Handel, MPH / Christopher Johnson, MS / Patricia Dietz, DrPH

The Public Health Nurse Workforce in U.S. State and Local Health Departments
Angela J. Beck, PhD, MPH / Matthew L. Boulton, MD, MPH

Agreement Between Self-Reported and Confirmed Cancer Diagnoses in New York City Firefighters and EMS Workers, 2001–2011
Rachel Zeig-Owens, DrPH / Andrea Kablanian, MPH / Mayris P. Webber, DrPH / Yang Liu, MS / Edward Mayerson, MA / Theresa Schwartz, MS / Nadia Jaber, RPA-C / Kerry J. Kelly, MD / David J. Prezant, MD

The Impact of the Affordable Care Act on Funding for Newborn Screening Services
Julia F. Costich, PhD, JD / Andrea L. Durst, DrPH, MS

Prevalence of Diabetes and Health-Related Quality of Life Among Rural-to-Urban Nong Zhuan Fei Migrants in an Urban Area of Northern China, 2013
Shauang Yan, MD / Xincai Hong, MBBS / Haiqiao Yu, MBBS / Zhen Yang, MBBS / Siying Liu, MBBS / Wei Quan, MBBS / Jiankai Xu, PhD / Liying Zhu, MD / Weilun Cheng, MB / Hong Xiao, MD / Heather Kitzman-Ulrich, PhD / Mark J. DeHaven, PhD

Population-Based Estimates of Decreases in Quality-Adjusted Life Expectancy Associated with Unhealthy Body Mass Index
Haomaio Jia, PhD / Mathew M. Zack, MD MPH / William W. Thompson, PhD

Health Department HIV Prevention Programs That Support the National HIV/AIDS Strategy: The Enhanced Comprehensive HIV Prevention Planning Project, 2010–2013
Holly H. Fisher, PhD / Tamika Hoyte, MPH / David W. Purcell, JD, PhD / Michelle Van Handel, MPH / Weston Williams, MHS / Amy Krueger, MPH / Patricia Dietz, DrPH / Dale Stratford, PhD / Janet Heitgerd, PhD / Erica Dunbar, MPH / Choi Wan, PhD / Laurie A. Linley, MPH / Stephen A. Flores, PhD

Law and the Public’s Health: Tax-Exempt Hospitals and Community Health Under the Affordable Care Act: Identifying and Addressing Unmet Legal Needs as Social Determinants of Health
Mary Crossley, JD / Elizabeth Tobin Tyler, JD, MA / Jennifer L. Herbst, JD, MBE, LLM

NCHS Dataline
Sandra S. Smith, MPH

From the Schools and Programs of Public Health: Flipping the Classroom and the Pedagogy: Using Active Learning Principles to Bring Leadership Training in Affirmative Sexuality to Public Health Education
S. Bryn Austin, ScD

From the Schools and Programs of Public Health: Mental Health Training in Schools of Public Health: History, Current Status, and Future Opportunities
Elizabeth Reisinger Walker, PhD, MPH, MAT / Jennie Kwon, BS / Delia L. Lang, PhD, MPH, MA / Richard M. Levinson, PhD, MA / Benjamin G. Druss, MD, MPH

Public Health Reports

More on PubMed Central PubMed Central
Additional volumes and issue numbers (1878-2007) can be
found on PubMed Central.
NEPHC Abstracts

System 1

Local Public Health Departments and Industrial Food Animal Production: Using the Ten Essential Services Framework

  • J. Fry , Johns Hopkins University
  • R. Neff , Johns Hopkins University
  • T.Burke , Johns Hopkins University

Background: As the nation rethinks the safety of the food supply, it is also critical to examine the role of public health agencies in protecting the public from the negative health effects associated with exposure to contaminants from industrial food animal production (IFAP) sites. This talk takes a preliminary look at what health departments are currently doing (and not doing) in these communities. A framework is presented that outlines appropriate roles for health departments and considers how such work could be funded. Methods: We used key informant interviews, a small survey, and a review of relevant documents to gather information. The Ten Essential Services of Public Health Model was adapted to provide a framework outlining appropriate actions health departments could undertake, including environmental public health tracking; educating; working with environmental and agricultural agencies at the federal, state, and local levels and other stakeholders; and conducting research. Results: We describe case studies of health department efforts and present survey results describing current health department practices. The “Ten Essential Services” framework is described. Survey results reflecting reactions to the draft framework are also presented. Conclusion: Health departments have an essential role to play in protecting communities affected by IFAP. These roles include monitoring, communicating public health knowledge, informing decision making, and collaborating on remediation activities. This framework can serve as a resource guide for health departments taking action to minimize the ill health effects of IFAP. It also has applicability for health departments serving communities facing other site-related environmental health threats.


System 1

Rapid Assessment of Subsistence Fishing Patterns in Urban Communities

  • K. Korfmacher , University of Rochester Medical Center

There is an extensive literature on the health risks of consuming contaminated fish. However, public “fish consumption advisories” tend to be overly simplified (i.e., “eat no more than one fish meal per month”) or presented in complex written form that is inaccessible to many low-literacy and ethnically diverse groups. Scientific research shows that health risks vary based on the types of fish eaten, how they are prepared, and levels of contamination. In addition, research is increasingly affirming the health benefits of eating fish. Meanwhile, patterns of subsistence fish consumption change rapidly as refugee resettlement, immigration, and economic forces affect the demographics of communities adjacent to contaminated waters. Effectively communicating these complexities to the diverse populations who consume fish presents significant challenges. Building on existing partnerships with community groups in Rochester, as well as the Buffalo Riverkeeper organization, we developed a rapid assessment protocol for determining which groups may be at risk from fish consumption in urban areas around Lake Ontario, viable outreach mechanisms to reach subsistence anglers, and educational strategies that promote prevention both through informed fish consumption and water quality protection efforts. This protocol may be used to assess the extent and nature of subsistence fishing populations in other communities in order to inform effective outreach strategies.


System 1

Human Health Benefits and Risks Associated With Consumption of Farmed and Wild Shrimp and Red Drum

  • J. Leffler , South Carolina Department of Natural Resources
  • G. Seaborn , NCCOS Center for Coastal Environmental Health and Biomolecular Research
  • E.Wirth , National Oceanic and Atmospheric Administration
  • C. Browdy , Novus International Inc.

Background: Seafood provides the essential fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) that help prevent and treat cardiovascular disease. However, there is significant public concern over the human health risk of chemical contaminants in marine organisms. Consumers also question the relative healthfulness of farm-raised versus wild-caught seafoods. Methods: We collected samples of shrimp and red drum from a variety of wild locations and from farmed foreign and domestic sources readily available to the American consumer. We analyzed edible tail muscle of the shrimp and skin-on fillets of the fish for fatty acids and 156 chemical contaminants. We expressed the contaminants as a percent of US Environmental Protection Agency Screening Values to evaluate potential chemical health risks. We calculated the number of 6 oz servings per week necessary to provide 250 mg/d of EPA and DHA, a quantity shown to reduce overall mortality by 17%. We then calculated the simultaneous intake of all contaminants associated with these servings. We calculated the individual lifetime carcinogenic risk level following standard US Environmental Protection Agency procedures. We directly compared the reduction in deaths resulting from beneficial fatty acids with the increased cancer risks from contaminant consumption. Results: Both the shrimp and red drum sampled were relatively free of contaminants, with most being below detection limits. A few specific samples of both shrimp and fish, both wild and cultivated, showed significant levels of polychlorinated biphenyls (PCBs), DDT, or inorganic arsenic. Conclusions: Farmed shrimp and fish had slightly higher levels of health-promoting EPA+DHA than wild products. In all cases, even the most severe, the fatty acid benefits of seafood consumption far outweighed the contaminant risks.


System 1

Contaminants in the Traditional Foods of the Yupik People of St. Lawrence Island, Alaska—Exposure Pathways, Collaborative Interventions, and Prevention

  • P. Miller , Alaska Community Action on Toxics
  • G. Welfinger-Smith , University at Albany
  • V.Waghiyi , Alaska Community Action on Toxics
  • D. Carpenter , University at Albany

The Yupik people, who reside in the northern Bering Sea region of Alaska on St. Lawrence Island, sustain traditional cultural ways of life that rely on a diet of marine mammals, fish, reindeer, and local plants. This study examined Yupik traditional foods for polychlorinated biphenyls (PCBs), chlorinated pesticides, and heavy metal concentrations. Community field researchers, working with traditional hunters and heads of households, collected approximately 500 samples of the diverse range of species, including plants, berries, fish, crab and other invertebrates, birds, and marine mammals that people of St. Lawrence Island depend on for their traditional diets. Preliminary results showed the meat/muscle tissue for most species and the plant species to be lowest in contaminant concentrations. For unlimited fish consumption, the Environmental Protection Agency (EPA) has published a risk-based consumption limit for PCBs in fish of 1.5 ppb (parts per billion) so as to avoid excess risk of cancer. Blubber tissues of marine mammals ranged from 35 ppb in walrus blubber tissue to 450 ppb for PCBs in polar bear blubber. The rendered oil samples contained by far the highest PCB concentrations of all samples tested other than polar bear blubber, ranging from 200 ppb in bearded seal to 450 ppb in ringed seal. Surprisingly, this was true even for bowhead whale oil, despite the whales' relatively low position in the food web. Reindeer had much lower PCBs levels than the omnivores and carnivores. We conclude that consumption of rendered oils and blubber are the major dietary sources of PCBs. Researchers are working with the community leadership on St. Lawrence Island to analyze additional PCB, pesticide, and heavy metal data and develop collaborative interventions that will eliminate sources and reduce exposures.


System 2

Bacteroides —A Better Indicator to Determine Fecal Contamination

  • D. Miskowski , EMSL Analytical, Inc.

Coliform and E.coli testing have been used for over 50 years. As our knowledge of these bacteria has increased along with the advent of molecular testing techniques such as polymerase chain reaction (PCR), we now know that looking for the traditional indicator bacteria using culture methods is problematic. This is particularly true when using these organisms to determine the presence of sewage contamination in tropical environments, soil, or indoor environments. The Environmental Protection Agency (EPA) has been evaluating alternative organisms to replace these sewage-indicator bacteria. This discussion presents an overview of the advantages and disadvantages of using the traditional indicator tests, EPA's research into alternative indicator organisms, as well as case study evidence that suggests that identifying Bacteroides using PCR may be a better indicator for sewage contamination.


System 2

Using the Social Ecological Model to Influence Water and Sanitation Behaviors

  • R. Goldberger , Alaska Native Tribal Health Consortium
  • T. Ritter , Alaska Native Tribal Health Consortium
  • J.Dobson , Alaska Native Tribal Health Consortium

Background: Providing modern water service in Alaska native villages has been a cornerstone of the Alaskan public health effort since 1957. To date, approximately 70% of villages have been provided modern water service. It was assumed that village residents would immediately begin using water service once provided. Data show that it takes approximately 14 years for a village to fully adapt to utilizing the water service. Issue: Alaska natives suffer from some of the highest rates of water-related disease ever documented. To reduce rates of infections, a formative approach to influencing water and sanitation practices is underway. Our efforts are focused in 4 villages receiving water service for the first time. The approach is based on principles of the social ecological model and seeks to influence behaviors at the individual, environmental, and policy levels. We also employ an adaptation of the National Patient Safety Foundation's “Ask Me 3” technique for communicating health behavior messages. Results: The project is funded by the Centers for Disease Control and Prevention (CDC) Healthy People and Healthy Communities Through Improved Environmental Health Services Program. We are in the second year of a 3-year project. Final results will be available fall 2010. Lessons Learned: Preliminary indications are that water use interventions should be specific and targeted. Cultural tailoring of messages appears to be essential when communicating sensitive information with indigenous populations. A formative approach is critical to developing successful water use interventions.


System 3

Domestic Well Water Quality Data and Reports for the Tracking Network: USGS and CDC Collaboration

  • A. Vaidyanathan , Centers for Disease Control and Prevention
  • J. Qualters , Centers for Disease Control and Prevention

Background: The Centers for Disease Control and Prevention (CDC) is leading the initiative to build a national Environmental Public Health Tracking Network (Tracking Network) by drawing on expertise from federal, state, and local agencies. CDC is collaborating with various environmental agencies to make environmental data accessible to users through the tracking network. This presentation will describe the domestic well water quality data and information available from the United States Geological Service (USGS) on the Tracking Network. Issue: Groundwater is a focus area for tracking and in many of the Tracking Network–funded states, the total number of people served by domestic supplies can be in the millions. The water quality of these domestic supplies is inconsistently regulated and generally not well characterized. Hence, it is important to understand distribution of groundwater contaminants, especially in areas with high domestic well water use. Over the past 4 years CDC and USGS have worked together to identify priority contaminants in the states funded for tracking by the CDC. On the basis of national summaries of detection frequencies and concentrations relative to US Environmental Protection Agency (US EPA) human-health benchmarks, 11 contaminants were selected for summarization of domestic well water quality data in the 16 funded states. Lessons Learned: Tracking Network provides information related to groundwater obtained through collaboration with USGS for the 16 Tracking Network–funded states. The data products that would be accessible to users through the tracking network are water quality data and indicators on the 11 contaminants from the National Water-Quality Assessment (NAWQA) database, and a summary report by state that analyses USGS water quality data with associated ancillary geospatial and water use data.


System 3

Collecting Geography for Drinking Water Quality Tracking

  • C. Wolff , California Environmental Health Tracking Program

Surveillance of drinking water contaminants poses a unique challenge for the developers of the Environmental Public Health Tracking Network (EPHTN). The lack of centralized spatial information on the extent of distribution systems prevents the linkage of subpopulations to water systems. If this information were available, the possibility opens for developing indicators and exposure assessment metrics for consumer populations served by public water systems. The California Environmental Health Tracking Program (CEHTP) identified the need for more accurate water quality contaminant indicators. The CEHTP also identified the need to prioritize resources toward assisting data system owners in enhancing their existing database systems for spatial integration. To address these needs, the CEHTP initiated the development of a reporting system that collects and organizes spatial information data that describe the extent of community water systems and that allow for the linkage of drinking water quality data to subpopulations. Divided into 3 phases, Phase 1 is near completion and involves the manual collection of water system boundaries, and the piloting of a browser- and role-based geographic feature editing system on a dynamic clickable map. The users of the system include water utility personnel, state water primacy/district engineers, and users from other regional jurisdictions, who have detailed knowledge of distribution system extents. Phases 2 and 3 involve the full release of the tool to all community water systems in California and collaboration with other state grantees and stakeholders to enable this methodology beyond California. This presentation will discuss how the data captured by this reporting system will address many of the complications in estimating water contaminant indicators, but not all of them. Additionally, other disciplines stand to benefit from the data produced by this system, such as emergency response or drinking water funding agencies.


System 4

Coastal Ecosystem Services and Human Health and Well-Being

  • S. Lovelace , National Oceanic and Atmospheric Administration
  • D. Chanda , University of South Carolina
  • D.Sanger , South Carolina Sea Grant Consortium

Background: As population increases in coastal counties, the need for ecosystem services increases even as the built environment challenges the services that ecosystems can provide. Evaluating the quality and changes in these services will allow us to understand the risks and benefits to human health and well-being associated with changes in land use, climate, sea level, and human use patterns. Issue: We are faced with changes in land use challenges ecosystem services such as food production, recreation opportunities, climate moderation, and stormwater control. Identifying indicators of ecosystem service decline and identification of the linkages between the availability of ecosystem services and human health will allow us to forecast the risks and benefits of differing types of coastal development and planning. Results: Evaluation of 19 small coastal watersheds in the southeastern United States provides an important indicator of ecosystem health and the level of services provided. During the summer of 2009 an initial hypothesis generating epidemiology study of multiple coastal watersheds in the South Carolina coastal area will provide an initial look at potential linkages between healthy ecosystems and human health. Identifying correlations will allow us to use indicators of ecosystem service availability to better understand the changes in human health in these areas. Conclusions: Evaluating the health of coastal watersheds answers ecosystem service questions such as the following: Can we swim in the water? Can we eat the seafood? Is our house becoming more susceptible to flooding? Using these data in comparison with human health data may further address questions such as: Can we take a walk and safely enjoy the aesthetic qualities of the ocean, sound, or bay? Can we live, work, and play nearby?


System 4

Introduction to Ecosystem Services: Our Life-Support System and Key to Well-Being

  • L. Jackson , US Environmental Protection Agency

Background: Human dependence on a healthy environment is intuitive. International efforts are raising the profile of this concept by characterizing environmental systems in terms of specific benefits to human well-being. This overview sets the stage for session presentations illustrating initiatives, data, tools, and opportunities across several US environmental agencies to link important public health outcomes with the status of ecological components and processes. Issue: The UN Millennium Ecosystem Assessment (2005) reported the findings of more than 1,360 experts worldwide that the state of the earth's environmental systems in many places may be inadequate to meet future population needs such as clean water, adequate food, sustainable livelihoods, and buffers from extreme events. Strategies for optimizing suites of ecosystem services can fortify these and other provisions for human well-being, defined as health, security, basic materials, social relations, and freedom of choice and action. Results: Community and regional assessments of ecosystem services are underway, and economic markets are emerging to facilitate protection, restoration, and trading of services, including carbon storage capacity and drinking water filtration. Nonmarket valuation of ecosystem service benefits to public health requires further research. Potential metrics include population burden of illness and disease, longevity, and carrying capacity. Lessons Learned: The concept of ecosystem services is advancing environmental research, management, and policy. Studies at societal scales from local to global are quantifying current and potential future supply of ecosystem services under various assumptions of human demand and competing uses for land and other resources. US environmental agencies seek increased collaboration with health organizations to explore and quantify the many human health outcomes that are attributable in part to the quality and supply of ecosystem services.


System 4

Dissemination of Ecosystem Data Through Tracking Network: Challenges and Opportunities

  • A. Vaidyanathan , Centers for Disease Control and Prevention
  • J. Qualters , Centers for Disease Control and Prevention

Background: The Environmental Public Health Tracking Network (EPHT or Tracking Network) addresses a critical information gap in understanding the relationship between environmental factors and disease. To explore this relationship further, it is necessary to tap into nontraditional sources of information for public health application. This presentation examines the use of ecosystem data in the Tracking Network; and describes the challenges involved and the potential benefits of incorporating ecosystem data into the Tracking Network. Issue: Ecosystem Services Research Program (ESRP) at the US Environmental Protection Agency (EPA) provides data related to natural ecosystems and its National Mapping initiative includes information on natural ecosystem processes, such as stormwater buffering, drinking water filtration, and heat-island mitigation, to vulnerable and expanding human populations. Information on some of these processes is relevant to public health and may provide a better understanding of the confounders when linking hazards and health effects. However, experiences gained from building a Tracking Network from disparate data sources reveal that there are several process requirements that have to be satisfied in order to include new data streams into the network. Establishing a clear understanding of customer needs and standards of practice for data use, establishing data transfer protocols, and developing public health messages to explain scientific content to a lay user are some of the many requirements that the Centers for Disease Control and Prevention (CDC) had to address before launching the Tracking Network. Conclusions: The Tracking Network provides important information on the environmental health status of communities and informs public health practice and policy. Ecosystem data are available at various spatiotemporal scales and may provide useful information in exploring relationships between environmental hazards and human health effects. Nontraditional data sources such as data on ecosystems can have direct public health application and enhance the utility of the network.


System 4

The Role of Vegetation in Mitigating Human Exposure to Urban Air Pollution

  • D. Nowak , US Department of Agriculture

Urban development is significantly altering our environment and human health by degrading air and water quality and increasing air temperatures and energy use. Healthy trees and forests in cities can help mitigate many of these negative effects by improving air and water quality, reducing atmospheric carbon dioxide, cooling air temperatures, and reducing building energy use. Understanding how city vegetation can affect air quality is critical to utilizing city vegetation to improve air quality and consequently human health. To help understand the effect of vegetation on air quality in cities, various research studies and new tools have been developed (e.g., These tools and research investigate urban vegetation in relation to pollution removal, air temperature cooling, carbon storage and sequestration, biogenic emissions, and building energy use. Utilizing these tools and understanding the research results will aid policy makers and public health professionals in supporting proper landscape designs and management to improve public health by facilitating lower pollutant emissions and lower concentrations of atmospheric pollutants. City vegetation affects air quality by changing local meteorology (e.g., lowering air temperatures), directly removing pollution from the atmosphere, emitting biogenic chemicals, and altering building energy use and consequent emissions from power plants. These factors combine to influence atmospheric concentrations of gases (e.g., ozone) and particles (e.g., PM2.5) (particulate matter) in cities.


System 5

Community Based Fish Consumption Advisory Case Study—Saginaw River, Michigan

  • S. Manente , Michigan Department of Community Health
  • K. Groetsch , Michigan Department of Community Health

Background: Michigan's Saginaw River has long been an area of concern designated by the United States and Canada for chemical contamination concerns (dioxins and polychlorinated biphenyls [PCBs]). Elevated concentrations of dioxins and PCBs found in fish caused the Michigan Department of Community Health (MDCH) to issue a public health fish consumption advisory (FCA) for the Saginaw River in 1978. Recent chemical analyses of Saginaw River fillets continue restrictive public health advisories today. Issue: The Saginaw River flows through the city of Saginaw (59,000 people). The city of Saginaw is 53% people of color with 28.5% of Saginaw residents living below the poverty line (3 times the state average). Based on an MDCH study of fish consumers fishing the Saginaw River, people of color, women, lower-income individuals, and shoreline fishers ate the more contaminated species of fish. Results: Over the past 3 years, MDCH has developed a productive relationship with community partners to increase awareness and knowledge about the FCAs by at-risk populations. Over the next 18 months, MDCH will be implementing a US Environmental Protection Agency–funded grant that will expand that collaboration. Community partners helped design the FCA message and communication strategy and will implement the distribution the information through numerous venues using a variety of methods. Lessons Learned: Community-based fish consumption advisory methods are best used with highly contaminated fisheries from which fishing and fish consumption is common. Working with local partners is effective at increasing environmental public health awareness at an affordable cost. Community-based fish consumption advisory methods deliver a more culturally appropriate message from a trusted local organization to the most at-risk population.


System 5

Pictures and Spoken Words: Doing Needs Assessment with Limited English Proficiency Populations

  • T. Eshenaur , Minnesota Department of Health
  • P. McCann , Minnesota Department of Health

Background: While historically the Minnesota Department of Health (MDH) has used a variety of outreach methods for fish consumption guidelines, the unexpected discovery of perfluorochemicals in fish in metro area lakes prompted renewed concern for limited English proficiency populations, particularly the Hmong. Issue: Those Hmong who are subsistence fishers constitute a vulnerable population and may not be reached by English language outreach efforts. Environmental health specialists met with and listened to Hmong fishers, youth, parents, and elders in several structured settings. The goal was to learn about cultural themes related to fish and health in Hmong culture, the kinds and amounts of fish consumed, and preferred ways of receiving information about fish. Results: The listening sessions provided a rich collection of eating habits, fish stories, recipes, reflections on contamination in fish, and suggestions for communicating with the Hmong community. These sessions also highlighted the need to work with a larger group of active fishers with limited English proficiency. In collaboration with a local chapter of Hmong sportsmen and the Minnesota Department of Natural Resources, staff conducted a unique needs assessment with novel techniques to engage participants in active responses using pictures, video, and spoken words. Participants were animated and enthusiastically provided qualitative and quantitative data on fish preferences and eating frequencies. Lessons Learned: Needs assessment of limited English proficiency populations requires the active participation of the target population. Using pictures and oral communication, the participants can provide quantitative and qualitative responses that provide information for the community as well as the environmental health staff.


System 5

Hook, Line, and Sinker: Developing, Delivering, and Testing Fish Advisory Messages for Latinos

  • M. Keating , Duke University
  • T. Connaughton-Espino , North Carolina Healthy Start Foundation
  • L.Richardson , North Carolina Division of Public Health
  • K. Kreblein , North Carolina Healthy Start Foundation
  • M. Miranda , Duke University

Federal and state public health agencies, including North Carolina, have issued fish consumption advisories for fresh and saltwater fish due to mercury contamination. Groups that are the least aware of advisories, and the most likely to consume higher amounts of high-mercury fish, are those with low-income/low educational attainment, limited English proficiency, and recent immigration status—all characteristics of the growing Latino population in North Carolina and across the United States. Avoiding fish consumption entirely is undesirable, as omega-3 fatty acids from fish are associated with better birth and developmental outcomes. Communicating fish advisory information to Latino anglers through traditional outreach channels is ineffective. In addition to the complexity of delivering complex risk/benefit messages about fish consumption, additional challenges arise in reaching the Latino population in ways that are culturally appropriate and effective. This project involved a partnership among Duke University, the North Carolina Supplemental Nutrition Program for Women, Infants and Children (WIC), and the North Carolina Healthy Start Foundation. Using information about advisory awareness and communication strategies collected by peer interviewers in Latino communities, we developed outreach materials for Latino men and women. Focus groups tested the messages and formats. WIC nutritionists were trained in using the materials, which were incorporated statewide into the WIC nutrition education curriculum. Video “health moments” were broadcast by a North Carolina Latino television station. We will emphasize the potential of partnerships between environmental scientists and social scientists, strategies for developing and delivering environmental messages to Latinos, and insight into risk communication and cultural differences.


System 5

Community Based Approaches for Fish Advisory Outreach

  • J. Maloney , Wisconsin Division of Public Health

Background: The Wisconsin lower Fox River is one of the largest Superfund sites in the nation. Contamination by polychlorinated biphenyls (PCBs) is spread over 39 miles of this river. Cleanup is just beginning to take place after more than 25 years of deliberation and coordination among the responsible parties and community groups involved in this effort. Issue: Given the size of the Fox River, extent of PCB contamination, and the popularity of fishing on this river, fish consumption information has to reach a number of communities. The Fox River area is rich in American Indian, Hmong, and Hispanic communities. In order to reach all the communities surrounding the Fox River contamination, Wisconsin had to partner with local health, community groups, and the Department of Natural Resources to reach these audiences. Results: (1) Increased awareness of fish consumption advisories on the Fox River, (2) provided fish consumption advice in 3 languages, and (3) established a variety of outreach methods as a result of the collaboration among groups. Objectives: Participants should be able to (1) recognize the value of subsistence fishing to American Indian, Hmong, and Hispanic cultures, (2) evaluate the need for a variety of approaches when educating diverse communities about fish consumption information, and (3) identify ways to establish partnerships with nontraditional groups in order to communicate health information.


System 5

Connecticut's Supermarket Outreach Program: A Collaborative Project With the Retail Food Industry

  • S. Rusnak , Connecticut Department of Public Health
  • B. Toal , Connecticut Department of Public Health
  • G.Ginsberg , Connecticut Department of Public Health
  • K. Foscue , Connecticut Department of Public Health

The state of Connecticut routinely issues a yearly fish consumption advisory for recreational fishermen that is based on routine sampling of fish fillets for contaminants, mainly mercury and polychlorinated biphenyls. Specific advice is given both to high-risk groups, which include pregnant women, nursing women, women planning pregnancy within a year, and young children, as well as the general population. General population consumption advisories are given for specific water bodies as well as a general one for the entire state. While developing these recreational fish consumption advisories, our program perceived the need for a fish supermarket sign, mainly for high-risk groups, because their primary fish source is supermarkets. As an alternative to legislation, our program developed a supermarket sign with the Connecticut Food Association that is being voluntarily posted at supermarkets across Connecticut. This was challenging because the Connecticut Food Association believed that any sign might decrease fish sales. The supermarket sign is based on a “traffic light,” an inverted triangle format where fish in the larger, green section can be eaten more often and fish in the smaller, red section should be avoided. The sign was focus-group tested to ensure that the information that it provides is most effective. Efforts to evaluate compliance concluded that 80% of fish supermarkets have posted these signs. Following development of the supermarket fish sign, our program devised a take-home coupon card in the same “traffic light” format to accompany the supermarket sign.


System 6

Recreational Exposure to Microcystins During Algal Blooms in Two California Lakes

  • L. Backer , Centers for Disease Control and Prevention
  • S. McNeel , California Department of Health
  • T.Barber , Siskiyou County Department of Public Health and Community Development
  • B. Kirkpatrick , Mote Marine Laboratory
  • C. Williams , GreenWater Laboratories
  • M. Irvin , Lovelace Respiratory Research Institute

We conducted a study of recreational exposure to microcystins among 81 children and adults planning recreational activities on either of 3 California reservoirs, 2 with significant, ongoing blooms of toxin-producing cyanobacteria, including Microcystis aeruginosa (bloom lakes), and one without a toxin-producing algal bloom (control lake). We analyzed water samples for algal taxonomy, microcystin concentrations, and potential respiratory viruses (adenoviruses and enteroviruses). We measured microcystins in personal air samples, nasal swabs, and blood samples. We interviewed study participants for demographic and health symptoms information. We found highly variable microcystin concentrations in bloom lakes (<10 µg/L–>500 µg/L); microcystin was not detected in the control lake. We did not detect adenoviruses or enteroviruses in any of the lakes. Low microcystin concentrations were found in personal air samples (<0.1 ng/m 3 [limit of detection]–2.89 ng/m 3 ) and nasal swabs (<0.1 ng [limit of detection]–5 ng). Microcystin concentrations in the water-soluble fraction of all plasma samples were below the limit of detection (1.0 µg/L). Our findings indicate that recreational activities in water bodies that experience toxin-producing cyanobacterial blooms can generate aerosolized cyanotoxins, making inhalation a potential route of exposure. Future studies should include collecting nasal swabs to assess upper respiratory tract deposition of toxin-containing aerosols droplets.


System 6

Wet & Healthy: Health Benefits of Aquatic Activity

  • B. Becker , Washington State University

Despite a wealth of scientific studies over the past several decades on the health benefits of aquatic exercise, health care providers remain remarkably unaware of these benefits. Obesity, diabetes, and cardiovascular disease in particular are positively impacted by aquatic activity participation. An overview of the science will be presented, along with recent research studies demonstrating the public health benefits of a broader use of aquatic exercise, both vertical and horizontal, in the management of these vexing public health concerns. The health benefits of aquatic exercise have been shown to equal or surpass other forms of exercise, including walking and running, in studies of the Cooper Clinic database of more than 30,000 men and women. These studies assessed overall health benefits of aquatic exercise with land-based walking and running, finding health effects comparable to both land activities, with the potential added value of aquatic activities' broader range of clinical applicability in specific populations. Review of the Cooper Clinic database of more than 4,000 men showed exercise swimmers to have less than half the mortality risk of sedentary men and, surprisingly, approximately half the mortality risk of exercise walkers and runners. All these effects are good reasons to promote aquatic exercise for wider public participation. There are tremendous potential public health benefits to be achieved through programs targeted at the most costly chronic diseases: hypertension, cardiovascular disease, arthritis and other musculoskeletal pathology, obesity, and deconditioning.


System 7

Contribution of Company Networks and Social Contacts to Risk Estimates of Between-Farm Transmission of Avian Influenza

  • J. Leibler , Johns Hopkins University

Background/Objective: As evidenced by the recent H1N1 outbreak, understanding pathogen movement in the context of industrial food animal production is critical in preventing influenza pandemics in humans. We examined the importance of company networks, as distinct from social contacts, in a model of the potential spread of avian influenza among broiler poultry farms in a poultry-dense region in the United States. The contribution of these networks to risk of between-farm disease transmission has not been previously studied. Methods: We conducted a national online survey of broiler poultry growers to collect data on frequency and nature of vehicular contacts among farms. We used stochastic modeling techniques to estimate between-farm daily contact rates and simulate the risk of exposure from a single infectious farm within a dense broiler chicken production region. Results: The median daily rate of vehicular contact by all sources was 0.82 vehicles/day. Risk of between-farm transmission was largely driven by company networks and was significantly increased by employment of part-time workers. The magnitude of exposure risk was dependent on the assumed duration of the infectious period at the index farm and viral survival on a vehicle, as well as company affiliation, with risk estimates ranging from <1% to 25% under varying parameters. Social visits were significantly less important in determining risk. Conclusions/Implications: Biosecurity interventions should be based on information on industry structure and company affiliation, and include part-time workers as potentially unrecognized sources of viral transmission. Modeling efforts in the context of industrial food animal production should consider company networks in addition to geospatial factors and pathogen characteristics. Restriction of social contact may be less relevant to preventing farm-to-farm transmission.


System 7

Predictors of Triatoma infestans Infestation and Chagas Disease

  • M. Christenson , University of Wisconsin–Madison
  • M. Levy , National Institutes of Health
  • J.Cornejo del Carpio , Direccion Regional del Ministerio de Salud
  • J. Patz , University of Wisconsin - Madison

Infestation of homes with Triatoma infestans , an important vector of Chagas disease in southern Peru, is common in the peri-urban shantytown communities of Arequipa, Peru. Analyzing the distribution of vectors is an important element of understanding Chagas disease risk. Household surveys in the peri-urban community of Nueva Alborada provided information about presence of certain animal and peri-domestic and domestic housing types. The study was carried out in conjunction with the Ministry of Health's insecticide treatments for T. infestans . We used backward stepwise selection to choose a best-fitting model. The statistical analyses of the data indicate that certain animal and housing types are associated with T. infestans infestation. We used ArcGIS to spatially analyze the data, which showed that distance from a home with 20 or more bugs is also very significant in explaining infestation. Identifying prevention strategies is crucial for this potentially fatal disease, since it has no vaccine, requires complex treatment, and has unreliable diagnostics. Confirming suggestions of previous studies, keeping animals out of bedrooms and improving housing structures are 2 effective strategies that could lower Chagas disease risk.


System 7

Wildlife, Wildlands and Infectious Diseases

  • P. Farnese , University of Saskatchewan

Up to 70% of emerging infectious diseases, such as SARS and HIV, originated in wildlife populations. It is commonly understood among policy makers, health care workers, and scientists engaged in the study of infectious diseases that infectious disease pathways exist between humans, animals, and wildlife. Thus, one might expect that Canadian animal, wildlife, and human health policy regimes for infectious disease would be highly coordinated. Unfortunately, animal, wildlife, and human health regimes are almost entirely disconnected. Instead of integration, policy silos dominate. Analysis of infectious disease policies demonstrates that by overemphasizing the human effects of infectious disease, policy makers have, in agricultural production systems, inappropriately focused on biosecurity strategies instead of critically analyzing how these systems undermine the efficacy of infectious disease management. Moreover, existing policies have failed to address the root cause of wildlife disease, namely that “new patterns of disease commonly develop in disturbed environments where species richness and diversity has been reduced, habitat has been fragmented and ecosystem processes of energy flow and material recycling have been simplified” ( CDN Wildlife Disease Strategy , 2004). The silo approach to infectious disease prevention and mitigation has increased vulnerability to the very diseases policy makers have sought to control in human populations. Moreover, the silo approach to regulation has resulted in the emergence of previously unknown infectious diseases and further undermined wildlife integrity, thereby continuing to place humans at risk.


System 7

HealthScapes: A Web Resource for Visualization and Analysis of Infectious Disease

  • M. Hahn , University of Wisconsin–Madison
  • N. Preston , University of Wisconsin - Madison

Background: For several decades we have witnessed a global emergence/resurgence of infectious disease, often linked with complex changes in environmental and socioeconomic conditions. While vast amounts of sector-specific health and disease data are available, there is a need to aggregate and unify these heterogeneous data sources. We hope to accelerate discovery, advance outbreak detection, and improve prevention measures by organizing information in a venue that fosters collaborative research across disciplines and national boundaries. Issue: HealthScapes is a Web-based application suite for managing, analyzing, and sharing data toward advancing biomedical knowledge and discovery. The specific aims are (1) To develop an interactive Web framework for analyzing data from disparate health and environmental sources across multiple temporal/spatial scales, (2) to combine open-source analytical, visualization, and simulation tools, while allowing users to plug in their own analytical software for more detailed site-based or disease-specific analysis, and (3) to accelerate the sharing of technology, data, and analyses via a networking platform that links users by location, disease, and analytical methodology. Results: HealthScapes will have the capacity to influence policy, improve prevention, and guide research. The rich data repository, advanced analytical and visualization tools, and secure data-sharing environment will allow scientific use to expand quickly. HealthScapes will catalyze discovery among users in developing countries in particular, with up-to-date environmental data and analytical tools. Lessons Learned: We envision a flexible tool that will be applicable in many contexts on many spatial scales. The technology exists; however, the challenge is to combine the tools in an accessible manner that serves the needs of the environmental health research community. HealthScapes has the potential for standardizing data collection and collaboration practices among those studying environment–health linkages.


System 8

Environmental Policy and Livestock Production: The Role of EQIP in Water Quality and Health

  • M. Bailey , Tufts University

As livestock production becomes more concentrated, appropriate management of the vast animal waste generated by US agriculture has become a serious issue for public health. Gastrointestinal disease from drinking water contaminated with livestock manure and eutrophication of waterways from manure nutrients are among the documented health risks. The most significant nonregulatory tool the government uses to mitigate these environmental externalities is the Environmental Quality Incentives Program (EQIP). In part, EQIP provides livestock producers with funds to support conservation practices (e.g., filters strips, waste lagoons) that will help improve water quality conditions. EQIP has come under attack recently as interest groups question whether it is sound government policy to financially underwrite manure management, especially for concentrated livestock producers who may already be regulated under the Clean Water Act. Sustainable agriculture advocates have criticized this aspect of EQIP as an unfair subsidy for manure management in confined, concentrated livestock systems. However, it remains unknown what kinds of conservation practices receive funding through EQIP livestock contracts for water quality improvements. To understand whether practices associated with confined production systems receive a significant share of EQIP funding for water quality, EQIP conservation practice and contract data from the US Department of Agriculture were analyzed. The data show that for EQIP livestock contracts with water quality tagged as a resource concern, $193.5 million or 47% of all payments went toward cost sharing for animal waste storage facilities, a practice typically associated with confined production. This research shows that federal conservation investments made through EQIP do appear to prioritize confined practices in their funding decisions for livestock and water quality.


System 8

Emerging Concerns With MRSA: Industrial Food Animal Production and Antibiotic Resistance

  • M. Davis , Johns Hopkins University
  • A. Peterson , Johns Hopkins University
  • J.Leibler , Johns Hopkins University
  • E. Silbergeld , Johns Hopkins University

Background: The rise of antibiotic-resistant bacteria, as demonstrated by the recent emergence of methicillin-resistant Staphylococcus aureus (MRSA), traditionally has been attributed to transmission in the hospital setting. However, a driving force in the emergence of resistant pathogens is the nontherapeutic use of antimicrobials as feed additives in industrial food animal production (IFAP), associated with resistance in both commensal and pathogenic bacteria. This practice contributes to the global reservoir of resistance through pathways of environmental dispersion. IFAP involves raising thousands of animals in a confined setting, often in geographic areas with high farm density. These factors promote bacterial evolution and genetic interchange. Issue: Animal-associated MRSA recently has been recognized as an emerging pathogen associated with IFAP. A key concern is whether the use of nontherapeutic antibiotics in animal feed drives resistance to clinically important drugs and promotes the emergence of pathogens such as MRSA. These issues concern public health professionals, agribusiness, workers, and rural communities. IFAP practices are poorly regulated. Opportunities for surveillance in rural or farming communities have been overlooked, and existing surveillance for antibiotic resistance (e.g., National Antimicrobial Resistance Monitoring System does not cover nonfood pathways. Results: We recommend phasing out nontherapeutic uses of antimicrobials in food animals. We also recommend improvements in waste management and other IFAP practices to protect worker and community health. Improved surveillance targeting the animal–human and human–environment interfaces and environmental tracking of pathogens is critical. Lessons Learned: IFAP practices may be a major contributor to the community spread of antibiotic-resistant bacteria. Environmental pathways from the farm potentially expose human communities to these pathogens. Improved regulation and surveillance may help control emergence of pathogens from farm environments.


System 8

Filthy Feed: The Risky and Unregulated Practice of Feeding Poultry Litter to Cattle

  • L. McKenna , Food Animal Concerns Trust
  • L. Isenhart , Food Animal Concerns Trust
  • S.Roach , Food Animal Concerns Trust
  • M. Cunningham , Oregon Public Health Division

Using animal waste as animal feed intuitively seems wrong. However, in areas of the United States where cattle and large poultry operations coexist, poultry litter (including manure) is routinely fed to cows. Poultry litter can contain disease-causing bacteria, antibiotics, heavy metals, feed ingredients normally prohibited for cattle, and even foreign objects such as dead rodents, rocks, nails, and glass. This material is collected from the poultry house floors, processed, and added to cattle feed because of its nutritional value. Feeding poultry litter to cattle creates unacceptable risks to human and animal health. Documented risks include the spread of mad cow disease, the development of antibiotic resistant bacteria, and the potential for exposure to toxic substances. The risk is further compounded by the absence of consistent regulation or surveillance. When the Food and Drug Administration (FDA) lifted its ban on feeding litter to cattle in 1980, the agency also relinquished its authority to regulate the practice. Despite a growing public recognition that food safety is of paramount importance, in 2008 the FDA again failed to ban this practice when strengthening rules to prevent the spread of mad cow disease. Our paper demonstrates that the FDA has the authority to reinstate its ban on litter feeding and makes the case as to why the agency should promptly do so. We discuss what constitutes “safe” feed and argue that the agricultural industry should not be allowed to profit from a practice that places such a heavy burden on the health of society.


System 8

Public Health Hazard From Hydrogen Sulfide Emissions at a Dairy CAFO in Minnesota

  • R. Messing , Minnesota Department of Health
  • D. Gable , Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry
  • M.Colledge , Agency for Toxic Substances and Disease Registry

Background: The Excel Dairy is a concentrated animal feeding operation (CAFO) north of Thief River Falls, Minnesota. The Minnesota Pollution Control Agency (MPCA) monitored hydrogen sulfide (H 2 S) at the dairy from May to October 2008 to determine compliance with Minnesota ambient air quality (AQ) standards. In response to citizen complaints and review of AQ data, the Agency for Toxic Substances and Disease Registry (Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry) conducted an exposure investigation for H 2 S at 3 residences for 3 weeks in July 2009. Issue: CAFO manure basins are uncovered and a source of H 2 S; nearby residents have experienced health symptoms (eye and respiratory irritation, headaches, nausea) and stress. Results H 2 S emissions from the CAFO were determined to be a public health hazard because emissions from uncovered lagoons were uncontrolled and unpredictable. Methods used to control emissions were determined to be ineffective, unapproved, and experimental, resulting in hundreds of recorded exceedances of AQ standards and health-based criteria. Lessons Learned: AQ monitoring is needed to support public health and regulatory actions. Even in the face of demonstrated violations of permits and AQ standards, timely and expeditious remedies are not available.


System 9

Harmful Algal Bloom Illness-related Surveillance System (HABISS)

  • L. Backer , Centers for Disease Control and Prevention
  • R. LePrell , Centers for Disease Control and Prevention

The public health impacts from exposure to algal toxins in drinking and recreational waters are unknown. There are no US federal regulations or guidance specifying allowable concentrations of algal toxins in water. To support public health decision making about harmful algal blooms (HABs), the National Center for Environmental Health at the Centers for Disease Control and Prevention developed the Harmful Algal Bloom-related Illness Surveillance System (HABISS). HABISS is a unique surveillance system collecting human and animal health data and environmental data describing HABs. The format is modular and can be expanded to suit local needs. Ten state grantees contribute data as part of a 5-year cooperative agreement, and 3 states contribute on a case-by-case basis. We conduct active case finding with additional partners, including Poison Information Systems, and by following up on HAB events identified in ProMed. The official roll-out of the latest version of HABISS occurred in the fall of 2009, and all 13 states are now contributing data. Currently, HABISS holds records of 1,500 bloom reports and 100 human and 20 animal illnesses. Ongoing initiatives include linking meteorologic conditions to HABs, adding a prediction capability, developing early warning bulletins, providing scientific data to inform discussion of global climate change, expanding the network to include international partners, and providing selected data to the national Environmental Public Health Tracking Network. State and local health departments have requested guidance on public health risks associated with HABs. HABISS provides a multistate picture of the occurrence of HABs and the characteristics of affected populations. HABISS data will be used to predict local HABs, thus allowing state public health and environmental health agencies to be proactive in preventing HAB-related illnesses.


System 9

The PNW HAB Bulletin: Early Warning for the Razor Clam Fishery in Washington State

  • B. Hickey , University of Washington
  • V. Trainer , Northwest Fisheries Science Center

Background: Domoic acid-producing Pseudo-nitzschia (PN) blooms are a recurrent problem in coastal shellfish along the entire Pacific coast of the United States. In Washington state, these toxic cells primarily originate from a single source region, in waters offshore of the strait that separates Washington and British Columbia. Issue: These cells can be ingested by razor clams on coastal beaches, resulting in amnesic shellfish poisoning (ASP) if ingested by humans. Because our past research has shown that transport from the source region to coastal beaches depends on a specific sequence of winds and ocean currents, prediction of the risk of landfall of toxic cells is now possible. Results: The Pacific Northwest Harmful Algal Bloom (PNW HAB) Bulletin pilot project, with support from the Centers for Disease Control and Prevention, has been developed to provide a comprehensive early warning information system for Washington coast ASP events. The bulletin builds upon the Olympic Region Harmful Algal Blooms monitoring program by automating the aggregation of data into a single location on a Web-based information dashboard. Information includes domoic acid in shellfish, PN cell counts, PN sizes, and critical assessment–level indicators; present and future winds; model currents from a existing state-of-the-art operational models and from ocean observing systems such as Northwest Association of Networked Ocean Observing Systems; location of the plume from the Columbia River, which likely modulates cell arrival at coastal sites; and analyses by local experts projecting the likelihood of occurrence of PN landfall and ASP events. Automating the retrieval of data into a single location allows rapid delivery of information to coastal managers. Conclusion: The forecasts in the PNW HAB Bulletin have increased the commercial, subsistence, and recreational harvest of razor clams while minimizing the health risks to consumers.


System 9

Gulf of Mexico HAB: Beach Conditions and Health Information Hotline

  • K. Nierenberg , Mote Marine Laboratory
  • B. Kirkpatrick , Mote Marine Laboratory
  • R.Stumpf , National Oceanic and Atmospheric Administration
  • L. Fleming , University of Miami
  • W. Stephan , Florida Poison Information Center
  • R. Weisman , Florida Poison Information Center

Florida red tides annually occur in the Gulf of Mexico, resulting from blooms of the marine dinoflagellate Karenia brevis, which produces highly potent brevetoxins. These toxins cause massive fish kills, neurotoxic shellfish poisoning (NSP), and a respiratory syndrome (particularly in asthmatics). The public health challenge is providing timely preventive information for Florida's residents and tourists about Florida red tide and it toxins. A unique collaboration, the Florida Department of Health (DOH), the Centers for Disease Control and Prevention, and public and private partners have established a linked network of information coupled with exposure and disease surveillance on Florida red tide. The National Oceanic and Atmospheric Administration Harmful Algal Bloom (NOAA HAB) Bulletin produces weekly reports of red tide locations using remote sensing and water monitoring data. These data are linked to real-time reports from beach sentinels at 31 public beaches in 9 counties. The beach sentinels provide periodic subjective reports using PDAs of the amount of dead fish, level of respiratory irritation among beachgoers, water color, wind direction, surf condition, and the beach warning flag. The data are transferred via Internet to a Web site at the Mote Marine Laboratory. The HAB Bulletin data are also linked to the Poison Information Center hotline (888-232-8635), which provides 24 hour/day free health information in multiple languages and reports cases to the DOH as part of ongoing HAB surveillance. In addition to ongoing collaborative research, beach signage, information cards, and a traveling exhibit have been developed. The system has proven to be robust and well received by the public, providing an overview of Florida red tide location with variability from beach to beach for users to minimize their exposure; it also provides access to human health information with trained professionals leading to improved surveillance.


System 9

CyanoHAB Risks in Florida: Developing Appropriate Public Health Response Strategies

  • A. Reich , Florida Department of Health
  • C. Collins , Florida Department of Health
  • R.Stumpf , National Oceanic and Atmospheric Administration
  • L. Backer , Centers for Disease Control and Prevention

Background: Recent CyanoHAB (harmful algal bloom) events have occurred in Florida, impacting large ecosystems in multiple watersheds. These events were associated with anecdotal reports of cyanobacteria-associated illnesses. Issue: During these events, there was no preplanned response from local health departments, making it difficult to implement consistent and appropriate activities. There was neither an “early warning system” for notification of pending CyanoHAB events for appropriate state and local entities nor a public health surveillance tool to capture potential CyanoHAB-related illness reports. Results: Florida Department of Health, together with key partners at the federal, state, and local level, has developed a holistic and integrated program for the development of county-specific public health response plans that draw on local experience and expertise. Elements of this program include a HAB Resource Guide and generic CyanoHAB county response plans (such as sample collection, epidemiology evaluations, outreach, and education). This methodology is currently being used to facilitate development of response plans meeting local county health department needs and capabilities. The development of new remote sensing systems will also provide additional information (similar to the Gulf of Mexico HAB Bulletin) to public health and environmental agencies in guiding event monitoring and response strategies. The implementation of a national HAB-related Illness Surveillance System (HABISS) will also promote the documentation and investigation of CyanoHAB-related illness.


System 10

The BEACHES Study: Health Effects and Exposures from Non-Point Source Microbial Contaminants in Subtropical Recreational Marine Waters

  • L. Fleming , University of Miami

Background: Microbial water quality indicators, in high concentrations in sewage, are used to determine whether water is safe for recreational purposes. Recently, the use of these indicators to regulate recreational water bodies, particularly in subtropical recreational marine waters without known sources of sewage, has been questioned. The objectives of this study were to evaluate the risk to humans from exposure to subtropical recreational marine waters with no known point source, and the possible relationship between microbe densities and reported symptoms in human subjects with random exposure assignment and intensive individual microbial monitoring in this environment. Methods: A total of 1,303 adult regular bathers were randomly assigned to bather and nonbather groups, with subsequent follow-up for reported illness, in conjunction with extensive environmental sampling of indicator organisms (enterococci). Results: Bathers were 1.76 times more likely to report gastrointestinal illness (95% confidence interval = 0.94–3.30; p = 0.07); 4.46 times more likely to report acute febrile respiratory illness (0.99–20.90; p = 0.051); and 5.91 times more likely to report a skin illness (2.76–12.63; p<0.0001) relative to nonbathers. Evidence of a possible dose response relationship was found between skin illnesses and increasing enterococci exposure among bathers. Conclusions: This study indicates that bathers may be at increased risk of several illnesses relative to nonbathers, even in the absence of any known source of domestic sewage impacting the recreational marine waters.


System 10

How Do Organic Aggregates Contribute to the Persistence of Aquatic Pathogens?

  • M. Lyons , University of Connecticut/Old Dominion University
  • J. Ward , University of Connecticut
  • F. C.Dobbs , Old Dominion University
  • H. Gaff , Old Dominion University

Background: Organic aggregates (i.e., marine snow, marine aggregates, lake snow, flocs, bioflocs) are microbial hotspots with elevated levels of biomass and productivity. Yet despite their ubiquity in recreational waters, these detrital-based aggregates are frequently overlooked during environmental sampling for infectious microbes (or their indicators) because aggregates are disrupted by traditional sampling methods such as plankton nets and Niskin bottles. The resulting lack of data is particularly problematic for mathematical models of the transmission of bacterial pathogens from an aquatic reservoir to their human hosts either directly (i.e., from ingestion of natural waters) or indirectly (i.e., via consumption of filter-feeding shellfish). Methods: We are developing a differential equation–based model to characterize the role particle aggregation may play in the prevalence and persistence of aquatic pathogens. Concurrently, we are conducting laboratory experiments to quantify critical parameters. Results: Targeted parameters include the relative growth rates of bacteria in aggregates compared to aggregate-free water (preliminary results: 3-fold higher growth rate for bacteria in aggregates) and the relative benefit gained by protection from UV radiation (preliminary results: 200-fold difference in survival rates for bacteria in aggregates). In addition, community-level physiological profiling of individual aggregates has revealed the aggregate-bound communities are measurably different from each other (preliminary results: 2- to 4-fold differences in outcomes such as number of carbon substrates utilized). Implications: Our novel findings suggest the microbial composition of individual aggregates may impact the ultimate fate of aggregate-associated pathogens (e.g., Vibrio parahaemolyticus, V. vulnificus , V. cholerae, V. alginolyticus, Aeromonas hydrophila , and Pseudomonas aeruginosa ) and consequently should be included in ecological models for pathogen persistence.


System 10

Climate Change Impacts on Harmful Algal Blooms That Cause Shellfish Toxicity

  • S. Moore , National Oceanic and Atmospheric Administration
  • N. Mantua , University of Washington
  • B.Hickey , University of Washington
  • V. Trainer , National Oceanic and Atmospheric Administration

Background: Microalgae in the genus Alexandrium produce potent toxins called paralytic shellfish toxins usually when they bloom. These toxins can accumulate in shellfish and cause human illness or even death if contaminated shellfish are consumed. Climate can influence the marine environment such that it may enhance or diminish the risk of these harmful algal blooms (HABs). The risk of HABs of Alexandrium in Puget Sound, Washington, can be modeled by identifying the annual window of opportunity (WOO) for bloom development and toxin production. HAB-WOOs of long duration indicate long periods of time when conditions in the marine environment are favorable for the development of toxic blooms that threaten shellfish safety. Objective: Determine if the annual HAB-WOO duration is related to climate variations and/or climate change. Methods: Trends in the annual HAB-WOO duration are examined from 1967 to present using long-term records of conditions in the marine environment. Interannual and decadal variations in the HAB-WOO are compared to indices of large-scale climate variations and climate change. Regionally downscaled projections of climate change scenarios from the Intergovernmental Panel for Climate Change are used to model the HAB-WOO until the late 21st century. Results: A step increase in the annual HAB-WOO duration occurred in the late 1970s, coincident with the sudden appearance of the paralytic shellfish toxins in Puget Sound. This increase also coincided with a climate regime shift that was locally manifested by persistently warmer air and water temperatures and lower streamflow in the Pacific Northwest—parameters that comprise the HAB-WOO. The annual HAB-WOO duration continued to increase to the present day, as did toxic Alexandrium blooms in Puget Sound. Implications: The annual HAB-WOO duration is influenced by climate and can be modeled allowing a long-term forecast of HAB risks in Puget Sound.


System 10

Modeling Bacterial Transport in Nearshore Waters

  • P. Roberts , Georgia Institute of Technology
  • D. Schwab , National Oceanic and Atmospheric Administration
  • N. Nekouee , Georgia Institute of Technology

A serious and complex issue relating to human health around lakes and oceans is exposure to pathogens and other bacteria at recreational beaches caused by local sources such as combined sewer overflow outfalls (CSOs) and contaminated rivers. They can result in beach closures and can be entrained into water intakes. This project focuses on the fate and transport of bacterial contaminants in coastal waters. The goal is to develop mathematical models to predict hazardous beach conditions and to improve design of related water infrastructure such as CSO systems and water intakes. River and outfall plume dynamics involve physical, chemical, and biological processes that span a wide range of spatial and temporal scales from meters to kilometers, and seconds to hours and days. Four comprehensive field experiments have been completed on a contaminated river plume entering Lake Michigan. The experiments involve simultaneous aerial photography and measurements of physical properties and bacteria. A critical condition is when the river is warmer than the lake, which occurs often in summer. It causes the plume to form a thin surface layer about one to 2 meters thick that spreads rapidly. The plume's behavior depends on lake currents and winds on the temperature differences, river flow, and lake turbulence. We have developed mathematical models of these processes that include hydrodynamics and chemical and biological kinetics. Three-dimensional hydrodynamic models for the far field include a coarse-grid model of the whole lake and a high-resolution model around the source. In addition, a separate near-field model of the small-scale plume hydrodynamics is being developed that will be coupled to the far-field models.


System 10

Detecting and Tracking Pathogens in Coastal Waters to Reduce Public Health Risks

  • J. Stewart , University of North Carolina–Chapel Hill

Background: Proper assessment of water and shellfish quality requires the ability to rapidly detect microbial contaminants. Unfortunately, traditional methods for assessing microbial water quality are slow and target bacteria that are not reliable indicators of viral and protozoan pathogens. Traditional methods also not distinguish among sources of pollution. Issue: This presentation will introduce novel techniques to detect and track microbes of public health concern in coastal waters. With these tools, resource managers will be able to better assess risks to public health and to better mitigate inputs of pollution into contaminated waters. Application of these novel tools is also providing insight into the manner in which land use and other human activities affect microbial water quality. Results: One study evaluating the impact of land use changes on the water quality of tidal creek systems has demonstrated that urban watersheds are more prone to contamination than suburban and forested areas, and that the upper intertidal reaches of creeks systems are more contaminated than the subtidal zones where monitoring programs typically sample. Validated assays are also being incorporated into epidemiology studies evaluating health risks at bathing beaches impacted by nonpoint source pollution. Lessons Learned: Overall, these methods under development will allow rapid, cost-effective, and specific water quality assessments; and will contribute to a broader view of how land-based activities affect water quality and human health.


System 10

Improving Shellfish Safety by Understanding the Genetics of Vibrio parahaemolyticus

  • M. Strom , National Oceanic and Atmospheric Administration
  • E. Landis , National Oceanic and Atmospheric Administration
  • R.Paranjpye , National Oceanic and Atmospheric Administration

Background/Objectives: Vibrio parahaemolyticus (Vp) is a marine bacterium capable of causing severe gastroenteritis in humans, usually via the consumption of raw shellfish. In 1995 Vp gastroenteritis became less episodic and more epidemic with the emergence in India and Asia of a more virulent strain serotyped as O3:K6. This strain spread eastward and was later implicated in outbreaks in South America, the US Gulf Coast, and Chesapeake Bay. While the clinical relevance of this strain and its derivatives is clear, other unrelated serotypes have emerged in infections in other areas, including O4:K12 (Washington state) and O6:K18 (Alaska). Interestingly, clinical infections in Washington have largely occurred in the absence of significant numbers of Vp carrying the virulence-associated gene tdh to trigger regulatory action. Major goals of this research are to determine if a clone of Vp with increased pathogenic potential has recently emerged, to determine the genetic basis for increased virulence, and to determine whether pathoadaptation is correlative with specific environmental parameters. Methods: Genetic and genomic comparison methods including multilocus sequence typing and suppressive-subtractive hybridization are being used to characterize the phylogenetic relationships and diversity of Vp in Puget Sound. We are also examining whether there are spatial, temporal, and/or environmental correlations with strains responsible for clinical infections. Results: While initial results show that there is considerable diversity of Vp at the genome level, the majority of clinical strains from Puget Sound are members of a distinct clonal group. Many environmental isolates form a second clonal group phylogenetically similar to the O3:K6 pandemic strain. Conclusions/Implications; This study demonstrates that application of genomics tools can be used to identify unique markers for virulence to improve risk assessment models.


System 11

Understanding Spatio-Temporal Dimensions of Environmental Assessments in Foodborne Illness Outbreaks Associated with Leafy Green Produce

  • M. Baloch , Centers for Disease Control and Prevention

Background: The alarming increase in the number of foodborne outbreaks associated with the consumption of leafy green produce has been a major cause of concern recently. Among 10,421 foodborne illness outbreaks reported during 1973–2006, 502 (4.8%) outbreaks, 18,242 (6.5%) illnesses, and 15 (4.0%) deaths were associated with leafy greens. Field investigations for recent outbreaks show an association between environmental contributing factors on growing fields and contamination in produce. Issue: A number of interventions have been devised to prevent or reduce the survival and proliferation of microbial contamination in produce from the farm to the fork. Identification of the source of contamination and environmental factors that contribute to pathogen survival and proliferation enhances the understanding of the key processes and interactions. This understanding is critical for devising effective prevention strategies. However, in many cases, the sources of contamination and conditions under which contamination might have occurred have not been identified. These investigations have focused solely on the farm fields identified in traceback investigations. Results: A systems approach that uses a watershed model and extends the outbreak investigation beyond the implicated farms from a conceptually 2 dimensional spatial approach to a 4-dimensional spatio-temporal approach on a watershed scale could help to understand the underlying causes of outbreaks, thereby contributing to prevention of similar outbreaks and improving public health. Lessons Learned: Investigations of fresh produce outbreaks should include analysis of groundwater–surface water interactions, land use practices, and run-off contaminant processes in areas outside the actual contamination site on a watershed scale.


System 11

The Role of Environmental Assessments in Understanding Systems in Which Food and Waterborne Illness Outbreaks Occur

  • K. Delea , Centers for Disease Control and Prevention

Issue: Studies suggest that 4%–12% of the estimated 211 million annual gastrointestinal illnesses in the United States may be attributed to water and 36% to food. Recent outbreaks have enhanced understanding of the interrelatedness and numbers of outbreaks that are occurring, and emphasized the importance of understanding the interconnectedness of systems. Background: The Environmental Health Services Branch at the Centers for Disease Control and Prevention (CDC) is working to answer surveillance, epidemiologic, behavioral, and environmental health research questions and identify emerging public health issues through the use of the environmental health triads, systems theory, and the collaboration of state and national partners. Illness surveillance and outbreak investigations are complex systems operating within the infectious disease ecology (IDE) model. The systems approach evaluates relationships between health and the overall pattern of health within populations, helping identify contributing factors leading to risk and/or illness and the root causes (environmental antecedents) of the risk factors. Therefore, the systems approach defines risk factors, system variability, relationships between risk factors, and how the relationships between risk factors cause system variability, all of which are important components to defining the disease ecology and achieving health promotion goals. Results: The Environmental Health Specialist Network (EHS-Net) is a collaborative forum of environmental health specialists whose mission is to improve environmental health using a systems approach and the IDE model. EHS-Net works in collaboration with FoodNet, OutbreakNet, and PulseNet to better understand the system in which food and waterborne illnesses happen. EHS-Net is a surveillance network collecting data from environmental assessments during food and waterborne illness outbreaks to identify and recognize the environmental antecedents and contributing factors for the specific outbreak. These data helps to make science-based recommendations and can be used to support policy.


System 12

Malaria and Deforestation in Mâncio Lima, Brazil

  • S. Olson , University of Wisconsin–Madison
  • R. Gangnon , University of Wisconsin - Madison
  • G.Silveria , Santo Antônio Energia, Porto Velho, Brazil
  • J. Patz , University of Wisconsin - Madison

Background: Malaria is the most prevalent vector-borne disease in the Legal Amazon, with about 500,000 cases occurring annually throughout the past decade. In this same region the deforestation rate ranges between 12,000 and 27,000 square kilometers per annum. Findings in the Peruvian Amazon suggest deforestation is an important risk factor for malaria incidence. New malaria reporting at localidades (submunicipalities) by the Programa Nacional de Controle da Malária allows us to test whether deforestation is directly associated with malaria risk in the municipality of Mâncio Lima in Acre State, Brazil. Methods: We analyzed yearly summarized slide-confirmed malaria reports from January 2003 to June 2008 for localidades in the municipality of Mâncio Lima, Acre State, Brazil. A 2006 map demarcating the boundaries of each localidade (n = 54) is used to link malaria reports with deforestation data from the PRODES project at 60 m x 60 m resolution. We developed a negative binomial generalized additive model that adjusted for spatial trends and estimates the average annual response of malaria incidence to cumulative percent deforestation, percent rate of deforestation since 1997, percent of cases with access to care within 48 hours of symptom onset, percent of P. falciparum malaria cases, percent of cases identified with active surveillance, yearly trends, and demographics. Results: Increased malaria incidence is significantly associated with more cumulative deforestation, lower rates of deforestation, and less access to care. Conclusions: At the localidade scale, we find deforestation is associated with malaria risk independent of spatial effects and differing access to care, supporting land management as a significant potential public health intervention in the Legal Amazon.


System 12

The U.S. EPA's Interdisciplinary Research Initiative on Biodiversity and Human Disease

  • M. Pongsiri , US Environmental Protection Agency

Recognizing the need for a better understanding of causal links between social stressors, biodiversity, and human disease transmission, the Environmental Protection Agency (EPA) developed a new Biodiversity and Human Health initiative to develop and sponsor long-term and pilot research projects. The approach is interdisciplinary, and it also involves decision makers as part of the research process, so that new scientific knowledge can better, and more quickly, be used to improve decision making on land use, ecosystem management, and integrated pest management (IPM). One of the goals is to better understand the environmental and social/behavioral factors affecting disease transmission so that we might develop environmentally based strategies to reduce disease incidence. And, with improved characterization of causal relationships, we can characterize the quantifiable benefits of healthy, diverse ecosystems in public health terms. EPA's Biodiversity and Human Health projects include the following: (1) Rutgers, New Jersey Dept of Environmental Protection, New Jersey Audubon Society—investigating the relationships among social perceptions, diversity in plant, bird, and mosquito populations and West Nile virus prevalence in urban wetland communities in northern New Jersey. (2) EPA, Smithsonian Institution, Gorgas Institute—examining mosquito species diversity and pathogen diversity across a disturbance gradient in the Panama Canal Zone and evaluating public health implications for nearby residential communities. Expected research results include improved understanding of the causal mechanisms linking biodiversity and disease; the development of tools that can help forecast risks to biodiversity and health; and information that can be used to value the health benefits of conserving biodiversity.




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