June11,2013AdvisoryPanelMeetingAgenda
Time 1:00
Agenda Item Welcome & Introductions Presenters Patricia McGovern, Chair Aggie Leitheiser 1:05 Legislative Update & Summary 1:15 Progress and next steps: newborn mercury biomonitoring Jean Johnson 1:20 Pregnancy & Newborns Exposure Study Jessica Nelson 1:30 Discussion 1:45 Recruitment and Consent Jean Johnson, Ruby Nguyen, Protocols for Pregnant Women & their Newborns Pat McGovern 2:15 Discussion 2:35 Refreshments Description/expected outcome Panel members & audience are invited to introduce themselves Information item. Panel members are invited to ask questions. Information item. Jean will review progress to date. Panel members are invited to ask questions. Discussion item: Jessica Nelson will discuss the data from the cord: newborn blood spot comparison, and the results of cord blood analyses for mercury, lead and cadmium. Questions to the panel:  What implications do these results have for ongoing biomonitoring of newborns?  What additional information is needed? The speakers will review protocols used in the National Children’s Study (NCS) and The Infant Development & Environment Study (TIDES). Questions for the panel:  What can MDH learn from the NCS and TIDES study protocols?  Can a clinic‐based protocol address issues of participation bias for surveillance purposes?  Are results likely to be generalizable?  Are minorities likely to be represented? 1 2:45 Biomonitoring Updates  PFC community meeting  Biomonitoring Summit Planning  NCS collaboration  Riverside Birth Study collaboration  Fond du La (GLRI)  Sawtooth Clinic Study Jean Johnson Jessica Nelson Jim Kelly Information item. Panel members are invited to ask questions and comments on updates in the meeting materials. 2:50 PFC Biomonitoring: Goals Jessica Nelson for an Expanded Sample Discussion item. Panel members will be asked to consider several possible goals for an expanded sample in the East Metro. 2:55 Discussion Questions to the panel:  Do panel members have a recommendation as to the stated goal of the expanded sample?  Should children or other special groups be targeted? Discussion item. Panel members are invited to ask questions and to comment on the data presented. 3:15 New Tracking Content: Arsenic in Private Wells Ed Schneider, Chuck Stroebel 3:30 Discussion Question to the panel: 
Do panel members have suggestions for improving the display and interpretation of private wells data? 3:45 Tracking Updates  New tracking webpages  New data on MN Public Health Data Access  New projects with CDC partners Chuck Stroebel Information item. Panel members are invited to ask questions and comments on these materials. 3:50 3:55 4:00 New business Audience questions Motion to adjourn Pat McGovern Pat McGovern Pat McGovern The chair will invite a motion to adjourn 2 TableofContents
June 11, 2013 Advisory Panel Meeting Agenda .............................................................................. 1 Table of Contents ............................................................................................................................ 3 Section Overview: Legislative Update and Summary ..................................................................... 5 Section Overview: Progress & Next Steps for Newborn Mercury Biomonitoring .......................... 7 Section Overview: The Pregnancy and Newborn Exposure Study ............................................... 11 Section Overview: Recruitment & Consent for Pregnant Women and their Newborns .............. 15 Section Overview: Biomonitoring Updates .................................................................................. 29 Section Overview: PFC Biomonitoring Goals for an Expanded Sample ......................................... 35 Section Overview: New Tracking Content: Arsenic in Private Wells ............................................. 39 Section Overview: Tracking Updates ............................................................................................ 61 Section Overview: Other Information .......................................................................................... 67 3 This page intentionally left blank. 4 SectionOverview:LegislativeUpdateandSummary
Aggie Leitheiser will briefly summarize legislative actions that are relevant to the Environmental Health Tracking and Biomonitoring (EHTB) program New initiatives for biomonitoring in the 2013 Session include:  Perfluorochemical (PFC) Biomonitoring in Eastern Metropolitan Communities. $313,000 appropriated in FY2014 and FY2015 to conduct a third round of PFC biomonitoring in East Metro communities. This testing was recommended by the state Environmental Health Tracking & Biomonitoring Advisory Panel.  Environmental Health Risk Initiative. $499,000 appropriated in FY2014 and FY2015 to fund environmental health tracking and biomonitoring work utilized by both the Minnesota Department of Health and the Minnesota Pollution Control Agency in the areas of chronic respiratory disease in urban areas and mercury levels in newborns and children in the state. (Governor’s Budget Request) Other legislative initiatives that will affect the Tracking and Biomonitoring program activities include:  Surveillance for Elevated Blood Lead Levels. $100,000 appropriated in FY2014 and FY2015 to respond to and prevent childhood lead poisoning. (Governor’s Budget Request)  Statewide Cancer Surveillance System. $350,000 appropriated in FY2014 and FY2015 to develop and implement a new cancer reporting system. This second‐
generation statewide cancer data collection system will meet changing state and federal requirements, and provide more detailed cancer information at the local level. (Governor’s Budget Request) Aggie will also describe a new state law (2013 Laws Ch. 82) governing genetic information, which provides MDH with express authority to continue collecting, storing, using, and disseminating biological specimens and health data for health department program operations, public health practice, and public health oversight activities. 5 This page intentionally left blank. 6 SectionOverview:Progress&NextStepsforNewbornMercury
Biomonitoring
Jean Johnson will review the Advisory Panel’s recommendations for further mercury and PFC biomonitoring and summarize both current and future projects that will take place under new state funding for Fiscal Year (FY) 2014‐15. Information item: Panel members are invited to comment and ask questions. 7 This page intentionally left blank. 8 Overview:ProgressandNextSteps
Jean will present a brief update on progress to date in addressing recent recommendations of the EHTB Advisory Panel for mercury and PFC biomonitoring. These include the following: December 2011: Recommendations for Follow‐up to the Lake Superior Mercury in Newborns Pilot Project. At this meeting, Advisory Panel members discussed questions raised by the results of the project and made the following recommendations for more study: Recommendation Progress to date Measure prenatal total mercury exposure The Pregnancy and Newborns Exposure in matched pairs of umbilical cord and heel Study, a collaboration with UMN TIDES stick blood spots in order to determine investigators, is nearly complete. Results whether direct comparison of blood spot of the 48 matched specimens for the concentrations to the EPA reference level cord:spot comparison will be presented at (based on cord blood measurement) is this meeting (June 2013). Questionnaire appropriate for informing public health data on demographics and fish action, and can be used for ongoing consumption are being analyzed. Lead biomonitoring. and cadmium test results are complete. Analysis of speciation results and a manuscript for publication are pending. Further refine the laboratory method and Ongoing. Mercury speciation of the cord publish the method. blood specimens to determine whether the species proportions affect the result and extraction efficiency is pending. Laboratory staff will present their progress at an upcoming panel meeting. Conduct additional biomonitoring of Staff identified 2 other locations of newborns in other parts of the state to existing newborn specimens in MN that determine the extent and sources of are available for mercury and have mercury exposure in Minnesota newborns. initiated 2 projects. Study updates will be presented. NEW: Discussion of recruitment and consent methods at this meeting begins the planning for ongoing biomonitoring with new state funding for FY 2014‐15. 9 June 2012: East Metro PFC Follow‐up Study, Recommendations The Advisory Panel recommended further study of PFC exposure in the East Metro community: Recommendation Progress to Date  Conduct a third round of  New state funding for FY2014‐15 biomonitoring in the same group of was enacted by the 2013 MN individuals who were tested Legislature. Planning for this next previously to further monitor the phase of PFC biomonitoring will decline in PFC blood levels over begin in July 2013. time.  Planning is underway. New state  Expand the sample of people from funding will support testing for 200 the East Metro to be tested for PFC additional people. At this meeting, levels, including new residents. panel members will be asked to clarify the goals of the expanded sample. 10 SectionOverview:ThePregnancyandNewbornExposureStudy
Jessica Nelson will present preliminary results of the MDH EHTB collaboration with University of Minnesota investigator Dr. Ruby Nguyen, the principal investigator for the Minnesota arm of The Infant Development and Environment Study (TIDES). The MDH add‐on to TIDES collects both cord blood and newborn blood spots in order to compare total mercury levels found in paired newborn cord blood and heel stick spots to aid in the interpretation of blood spot results from the MDH Mercury in Newborns in the Lake Superior Basin pilot study. The collaborative study also analyzed the cord blood for lead and cadmium and, later in the summer, will speciate mercury in cord blood samples to ascertain the inorganic and methylmercury content. The study is also analyzing TIDES questionnaire data to learn whether demographic, behaviors, or other characteristics of the mother are associated with mercury, lead, and cadmium levels in the newborn. Questions for the panel: 
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What implications do these results have for ongoing biomonitoring of newborns? What additional information is needed? 11 ThePregnancyandNewbornsExposureStudy
Background The Pregnancy and Newborns Exposure Study, an EHTB collaboration with University of Minnesota investigator Dr. Ruby Nguyen, is an add‐on to The Infant Development and Environment Study (TIDES). TIDES is measuring in‐utero exposures to developmental toxicants and investigating their association with neurodevelopmental outcomes in the child at birth and at one year of follow‐up. The MDH add‐on will compare total mercury levels found in paired newborn cord blood and heel stick spots; the data will aid the interpretation of the blood spot results from the MDH Mercury in Newborns in the Lake Superior Basin pilot study (as recommended by the Advisory Panel). TIDES recruited pregnant women during their first trimester visit at the University Fairview‐Riverside prenatal clinic in Minneapolis. All women who were enrolled in TIDES at the start of the Pregnancy and Newborns Exposure Study period (June 1, 2012) and who had not delivered their infant were mailed a letter during their third trimester informing them about the MDH study. During a third trimester clinic visit, participants were invited to participate by TIDES study staff. If they consented, they signed a separate UM study consent form. Status Recruitment and specimen collection are complete. A total of 48 matched pairs of infant cord blood‐newborn bloodspot specimens were collected by hospital staff and transferred to the MDH Public Health Laboratory for analysis. Newborn bloodspot specimens were not available for 3 women, so the total number of cord blood samples is greater (n=52). Cord blood analyses for total mercury, lead, and cadmium levels are complete. Results letters were mailed to participants via UM‐TIDES study staff, in accordance with study protocol. One specimen exceeded the action level for mercury (5.8 µg/L), and this participant received a special letter. No specimens exceeded the action level for lead (5 µg/dL). Although participants were given the option of speaking with EHTB physician consultant, Mary Winnett, MD, for individual medical consultation, no participants contacted Dr. Winnett. At the time of this update, newborn bloodspot analyses for total mercury were complete and undergoing QA/QC review. Results will be presented at the Advisory Panel meeting. Cord blood samples will also be analyzed for speciated mercury. These analyses will happen later in the summer. Preliminary results: cord blood Table 1 presents the distribution of cord blood results. Mercury was detected in 65% of cord blood samples, lead in 46%, and cadmium in 67%. For mercury, levels measured ranged from non‐detect to 8.34 µg/L, with only one sample above 5.8 µg/L. 12 Table 1. Cord blood distribution (n=52) Hg Pb (µg/L) (µg/dL) 0.311 0.299 MDL 35% 54% % non‐detect ND ND Minimum 8.34 1.32 Maximum 0.65 0.21 Median 3.47 0.88 95th %ile Cd (µg/L) 0.22 33% ND 0.47 0.28 0.46 Next steps Once newborn bloodspot results are available, the full data analysis will begin. We will look at the distribution of newborn bloodspot results and compare the proportion greater than 5.8 µg/L to findings from the MDH Mercury in Newborns in the Lake Superior Basin pilot study. We will calculate the ratio of cord blood‐to‐newborn bloodspot mercury levels and examine the distribution of this ratio. We will determine whether variability in hematocrit levels or speciated mercury (when available and if feasible) contributes to variability in the cord blood‐to‐spot ratio. We will analyze TIDES questionnaire data to determine whether demographic, behavior, and other characteristics of the mother are associated with mercury, lead, and cadmium levels. We have received the following data from TIDES:  Mother’s age  Child’s month of birth  Seafood consumption (At how many meals [in typical week] did you consume seafood?)  Consumption of food that is “organic, ecofriendly, chemical‐free or environmentally friendly”  Consumption of food that is “grown, raised, or caught by you or your family and friends”  Smoking, exposure to secondhand smoke  Race and ethnicity  Education  Household income  Home characteristics 13 This page intentionally left blank. 14 SectionOverview:Recruitment&ConsentforPregnantWomen
andtheirNewborns
With the new state budget for FY2014‐15, EHTB expects to receive an additional 2 years of support for ongoing biomonitoring of mercury in newborns and children. Staff will soon begin developing protocols to meet these public health goals: to measure the extent to which newborns in different parts of the state are exposed to potentially harmful levels of mercury during prenatal development, to determine whether some groups are more exposed than others, and what sources, in addition to fish consumption, contribute to the exposure. As a first step, we will address critical questions about recruitment and consent methods. Recruiting and obtaining consent to study pregnant women and their newborns poses challenges that range from identifying women in their early months of pregnancy to ensuring that participants in the study represent the diversity of the larger population. These presentations report experiences from three different activities: the EHTB pilot projects, The Infant Development and Exposure Study (TIDES), and the National Children’s Study (NCS).  Jean Johnson will briefly review methods used for recruitment and consent in three EHTB pilot projects, along with the participation rates obtained with each method.  Pat McGovern will compare and contrast several methods used in the NCS to identify, recruit, and obtain consent from pregnant women using a probability‐
based sampling approach and will discuss the strengths and shortcomings of each.  Ruby Nguyen will review the methods used for clinic‐based recruitment and consent in the TIDES project, both in Minneapolis and in sister TIDES studies elsewhere in the US. Questions for the panel: 
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What can MDH‐EHTB learn from the NCS and TIDES study protocols that will guide future protocol decisions in MN? Can a clinic‐based protocol address issues of participation bias for surveillance purposes? Are results likely to be generalizable? Are minorities likely to be represented? 15 This page intentionally left blank. 16 EHTBPilotProjectRecruitment&
ConsentofPregnantWomen,Newborns,andChildren
Jean Johnson The EHTB pilots have demonstrated several different methods for recruitment and consent of participants for biomonitoring. This presentation reviews the participation rates obtained with each of these methods, which ranged from 44‐65% of those who were identified and invited, and who subsequently provided consent. Minneapolis Children’s Arsenic Study This study used household‐based recruitment of families with children age 3‐10 over a three‐month period. The recruitment goal was 100 children to provide a urine specimen. The study targeted homes with known soil arsenic concentrations that were above a background level. The approach was door‐to‐door with advanced mailings in English and Spanish. Both Somali and Spanish speaking recruiters were used to visit homes where needed. Gift cards to local stores were offered as incentive. The participation rate was low. A total of 883 households on 511 properties were identified and contact attempted. Few households met the study criteria for children. A large number of properties (12%) were no longer occupied. Only 47 households responded and 40 children were selected. Expanded Recruitment: Letters were mailed to 2,652 households in the study area inviting participation (all with soil testing for arsenic at or below background levels). An additional 25 children were recruited. From all responding households, a total of 119 eligible children were identified and all were invited to participate. Of those, 65 (55%) completed the study (consent and specimen collection). Riverside Birth Cohort Study of Pregnant Women This project used mail and clinic‐based recruitment of pregnant women already enrolled in a birth cohort study, with a goal to recruit 100 women (to include 30 Hispanic, 30 non‐Hispanic black) for urine sample collection and testing. Gift cards were offered as incentives. Out of 122 women from the birth cohort contacted, 79 (65%) consented, and a total of 66 women participated by providing a urine specimen. Very few Hispanic women visited the clinic. Special efforts to recruit Somali women with translated materials were not successful. Only 4 Hispanic and 8 African American women participated. Lake Superior Mercury in Newborns Study For Minnesota babies, recruitment was done via a mailed consent to the mother after the birth. Newborns were selected from the newborn screening database. About 10% 17 of newborns were excluded due to pregnancy complications or if the infants died or were born with certain health problems. This was done to avoid causing undue stress to the parents. An additional 25% were excluded because the quality of the blood spots was insufficient for analysis. Eligible mothers were mailed a letter explaining the study, requesting that they return an enclosed consent form, and were provided information in a brochure about safe fish consumption. In addition, local public health nurses visited some homes and provided materials and consents. A total of 1,130 mothers contacted (44%) returned the consent forms and agreed to participate. 18 RecruitmentandEnrollmentofPregnantWomen:
TheNationalChildren’sStudyVanguardStudy
Pat McGovern, PhD, MPH Background The National Children’s Study (NCS) has tested four forms of recruiting women into a pregnancy cohort study using a probability‐based sampling approach, including:  Household‐based,  Enhanced Household‐based,  Provider‐based, and  Direct Outreach (i.e., High‐Low Intensity). Each approach varied in effectiveness and bias. A summary of the yield and bias of each strategy follows, using data from January 2013 as reported at the February 2013 NCS Federal Advisory Committee meeting notes.1 The Original Vanguard Study (OVS) used a household‐based approach where there was broad community engagement to create awareness of the study, followed by mailings to all households in randomly selected neighborhoods. The mailing briefly informed households of the study and alerted families that study staff would be in their neighborhoods during particular days and times. The study staff would go door to door to identify households with age‐eligible women, interview those women for study eligibility, and invite those eligible to participate in the study. Results from 18 months of recruitment in 7 study centers revealed early assumptions about results of household enrollment were not supported by the data: only 10% (N= 3,100) of the 30,900 age‐
eligible women screened met eligibility criteria of being pregnant or trying to conceive; 63% (N=1950) of eligible women consented to participate. Subsequently, the NCS program office authorized 30 study centers to test three Alternative Recruitment Strategies (ARS), assigning 10 study centers to each ARS. Alternative Recruitment Strategies The Enhanced Household‐based Recruitment (EHBR) Strategy used “best practices” in recruitment learned from the original 7 Vanguard Study Centers as a second generation of household‐based recruitment. These included: hiring study staff from the neighborhoods where the potential participants lived, increased use of advertising, media (radio and television ads); and increased community engagement practices. Using a shorter recruitment period (14 months vs. 18 months), this strategy slightly increased identification of eligible women (pregnant or trying to conceive) from 1
National Children’s Study February 2013 NCS Advisory Committee Briefing Book, Recruitment Data Update; retrieved 5/21/13 at http://www.nationalchildrensstudy.gov/about/organization/advisorycommittee/ Pages/ february2013ncsacbriefingbook.aspx 19 screening to 13% (from 10% in the OVC) and enrolled higher percentages of eligible women 67% (vs. 63% in the OVC). The Provider‐based Recruitment (PBR) Strategy identified prenatal care providers in a specific county to identify women whose addresses were in the randomly selected neighborhoods and then recruited women from those providers using mailings and follow‐up calls. Using the same 14 month recruitment duration as the EHBR approach, this method greatly increased identification of eligible women (pregnant or trying to conceive) from screening to 76% (vs. 10% from OVS and 13% in EHBR), and enrolled higher percentages of eligible women 75% (vs. 63% in the OVC and 67% in EHBR). The Direct Outreach approach used broad community outreach throughout the county in addition to intense outreach in the randomly selected neighborhoods to create awareness of the study. Then household mailings were sent to all listed addresses in the selected neighborhoods to invite residents to call the study center if there were age‐
eligible women in the household to see if any that were study eligible. Using an 11 month recruitment duration, this method identified 18% of eligible women (pregnant or trying to conceive) from screening (vs. 10% from OVS, 13% from EHBR, 76% from PBR), and enrolled 82% of eligible women (vs. 63% in the OVC, 67% in EHBR, 75% from PBR). Because recruitment in the three ARS was more efficient than in the OVC, the NCS has only reported issues of bias on the ARS. The Provider‐based approach was deemed most efficient for identifying pregnant women (not surprising since they are recruiting through contacts with prenatal care providers). Racial and ethnic diversity of participants varied across the strategies. The most diversity was associated with Enhanced Household‐based Recruitment (38% nonwhite, 25% Hispanic), followed by Provider‐based (36% nonwhite, 14% Hispanic), with much less diversity seen in the Direct Outreach approach (22% nonwhite, 5% Hispanic). The Direct Outreach approach reported the highest proportions of women who spoke English, had earned college degrees, were married, and were ages 25 years and older relative to the other two strategies. This outcome is associated with a recruitment strategy that requires women from the community to take the initiative to contact study staff for eligibility screening. 20 ProtocolforPregnancyCohorts:TheInfantDevelopmentand
EnvironmentStudy
Ruby Nguyen, PhD Introduction The protocol outlined here reflects that of an NIH‐funded pregnancy cohort that recruited women between 2010–2012, with infants born as recently as January 2013. The aim of “The Infant Development and Environment Study” (TIDES) was to determine the association of an environmental toxicant during pregnancy with the urinary‐genital–
reproductive anatomy of neonates, and to provide normative data on these anatomic measures. The NIH‐funded study represents four geographically diverse centers, one of which was from the University of Minnesota. Women were enrolled in the first trimester of pregnancy and contacted each trimester for data collection. A survey and a biospecimen were provided in each trimester. Biospecimen collection was timed to match with women’s general obstetric visits. The study also required consent to examine the neonate before hospital discharge to measure anatomy and to abstract medical charts for characteristics of the labor, delivery, and neonate. Approximately 200 pregnant women consented and completed the study in Minnesota. Minnesota participants tended to be more homogeneous, therefore, when appropriate, this document will describe methods that other sites used to incorporate a greater distribution of racial and socio‐demographic characteristics. Description of the Clinic The University of Minnesota site recruited pregnant women from their first trimester of pregnancy and followed them through the discharge of the mother and child from the hospital after delivery. Pregnant women were recruited in one obstetrics clinic affiliated with the University. The study excluded women who planned to deliver their infant at hospitals that were not affiliated with the University, although women who unexpectedly delivered elsewhere and whose hospital allowed a clinical exam at birth were asked if they would like to continue in the study. The obstetrics clinic is in Minneapolis, on the University of Minnesota‐Fairview campus. The clinic originally was staffed exclusively by University clinicians, but about one year into the study the clinic merged with providers from the Fairview system. Most clinicians at the Fairview clinic were already affiliated with the University of Minnesota, often as clinical preceptors, medical students, or adjunct faculty members. After the merger, the sampling population comprised all patients seen in the combined clinic. 21 Developing Clinical Collaboration Identification of an appropriate clinic for sampling and collaboration The TIDES study aimed to determine the effect of a ubiquitous exposure and to provide normative data on neonate anatomy from mothers and neonates across the country. Therefore no particular population of pregnant women was targeted in Minnesota. The study investigators identified appropriate obstetrics clinics with the following parameters in mind:  A clinical protocol that involved a clinic visit for a woman in her first trimester of pregnancy;  A sufficient number of women who were seen in the first trimester of pregnancy;  A sufficient number of women who continued care until the third trimester of pregnancy;  A sufficient number of women who delivered at the affiliated hospital;  An established history of collaboration with researchers. Establishing collaboration with the clinic and hospital administration After identifying a potential clinic for collaboration, the investigators approached the clinic’s medical director. For the Minnesota study, the medical director was a faculty member of the University of Minnesota medical school who was familiar with the study investigators. Discussions with the medical director included: 
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The aims and public health importance of the study; The nature of the involvement of the participants; The preliminary nature of the involvement of the study staff; and The impact of this study on the field and potentially on the individual patients themselves. In these discussions, we emphasized that we considered the medical director and her staff as collaborators and that both parties would design their involvement together. After the medical director had considered our request and taken it to her administration, we considered her to be a full collaborator and named her as an investigator on the study. Establishing collaboration with the clinic staff Once the medical director and other administrative staff had agreed to participate, we established the details for the study from: identification of potential participants, to pre‐
clinic visit and visit recruitment, and data collection during defined clinic visits. We sought collaboration through multiple face‐to‐face meetings with all levels of the clinic staff. Study investigators met with the physicians and nurse midwives at their monthly providers’ meeting to describe the study and answer questions ranging from the scientific rationale and significance of the project, to the required activities of the providers. As our study involved no appreciable effort from the physicians and nurse 22 midwives, we sought to involve the certified nursing assistants with recruitment (see below). The provider meetings offered important insights into the clinic visits and the procedures for labor and delivery, which were needed for the neonate assessment. Finally, the clinicians were able to inform the study epidemiologist about the demographics of the clinic population, including characteristics of women who might not seek a first trimester clinic visit (and would therefore be ineligible for our study, lest they create potential bias). In collaborative meetings with the nursing staff, the study coordinator and other study staff met with the nursing supervisor and certified nursing assistants (CNAs) who roomed the patients (see below). Through these in‐person meetings, the study and clinic staff developed a flow of work that would minimize the unpaid effort from the CNAs, yet provide sufficient support for study recruitment. In addition, these meetings helped to develop an overall protocol that would minimize intrusion of the study on the operational needs of the clinic staff (e.g. space, number of people in the clinic). Establishing collaboration with the laboratory staff The study coordinator and investigators consulted with the clinic and laboratory staff multiple times to establish procedures to acquire blood from the study participants. The obstetrics clinic sends patients to Fairview’s outpatient laboratory for blood collection. Therefore, study staff needed to provide a laboratory request sheet for each woman. The one‐time blood sample was collected as a part of each woman’s routine blood draw, with an excess amount provided to the study. With the laboratory request sheet and multiple consultations with the study staff, the outpatient laboratory was able to collect the whole blood and store it at an appropriate temperature for the short term. Study staff were aware of when a woman was expected to provide her blood sample and could thereby schedule a pick‐up of samples from the laboratory within a few days. Our study also collected maternal urine in each trimester. Urine collection, unlike blood collection, is performed in the obstetrics clinic. Study staff were able to anticipate when a woman would next come for a clinic visit in which she would provide a routine urine sample. After the clinic staff tested the urine for routine medical parameters (e.g. glucose and protein), the remaining sample was available for the study. Study staff then aliquoted the urine into study‐specific containers, placed into a study identified box, and temporarily froze samples in the clinic laboratory’s freezer. Recruiting Pregnant Women Identification of potentially eligible women using scheduling calendars Our collaborating clinic used an electronic scheduling system. When women scheduled their first obstetrics appointment, the scheduler entered the visit as an “OB1,” a first obstetric visit. Using this term, our study staff worked with clinic staff to identify lists of women coming to the clinic each week who were denoted as OB1. At 23 the beginning of the study, our study coordinator was given access to the schedule, but we learned that it was just as efficient for clinic staff to provide lists of women coming for their OB1. Using the latter approach minimized the study staff’s need to access clinic records. Originally, we had proposed that the study staff identify these women to reduce the often unpaid effort of the clinic staff, but in the end, the request was minimal, so the clinic staff provided the names and home addresses for potentially eligible women. Pre‐clinic visit notification about the study to potentially eligible women Once a woman was identified as a potential participant, she was sent a letter signed by the medical director of the clinic and the principal investigator of the study. The letter told the woman that she had been identified as someone who potentially fit the criteria of a study in which the obstetrics clinic was collaborating. The letter gave the study coordinator’s name and contact information, and told the recipient that a study team member/recruiter would likely be at her first clinic visit to discuss any questions that she might have, and to consent and enroll her into the study. The letter also included a flyer about the study that featured the study logo. Note: A detailed human subjects protocol is used for contacting potential participants using medical lists, such as scheduling, because these lists contain medical information (in this case, that the woman is pregnant). A fluid recruitment protocol Study staff worked with the clinic to develop a fluid recruitment protocol that allowed contact with the potential participant at each stage of her initial clinic visit. Study staff were present in the clinic waiting room at times when the clinic was expected a high attendance of OB1 patients, or when a patient had expressed interest in speaking with the study staff. Staff generally had a small sign with the study’s logo (?) that signified their role as study staff. When possible, study staff were also given a small space behind the clinic receptionists to converse privately with potential participants. Printed material in the exam room Study staff developed a flyer that was placed in each of the clinic exam rooms. Through conversations with the clinic staff, we learned that women/potential participants spent some time in their exam room alone, and that seeing and reading printed material about the study would assist recruiting. Clinic staff to notify the women about the study Through discussions with the clinic staff, we learned that the CNAs who did the patient “rooming” were the people who spent the most time with the patients/potential participants, aside from the physicians and nurse midwives, who were too busy to discuss research opportunities. Therefore, the study staff contacted the nursing supervisor to request that the CNAs introduce the study to the potential participant. Their message was something to the effect of: “The clinic is involved in a study that you 24 may be interested in. A person from that study is here today. Let me know if you are interested in speaking with her at the end of your visit. She can tell you more about the study and how to get involved.” Study personnel to answer questions after the clinic exam If a woman expressed interest in the study, a study team member was available to meet with her after her clinic visit. The study staff worked with the clinic administration to find an appropriate space to speak with the woman in private or semi‐private. The space available to our staff was a small room directly behind the clinic’s reception desk. Because it had no door, we could not achieve complete privacy, but the nature of the conversation did not warrant complete privacy. During this conversation, the study staff described the study, its requirements and compensation, and then discussed the consent. If the woman agreed to participate, she provided written consent at that time with the study staff as witness. Consenting Pregnant Women Women were consented for the study in person at the same clinic visit in which they were recruited. At the Minnesota site, only English speakers were eligible to participate. At other geographic sites, written consent forms were also available in Spanish. Women could provide consent to each aspect of the study, for herself and for her neonate’s involvement. A separate consent, if given, allowed future use of stored biospecimens for purposes unrelated to the primary aim of this study. The human subjects committee for this study was a joint entity between the University of Minnesota and the Fairview Health System. All consents for the main study were listed on one form with the ability to indicate (check) “yes” for consent. Consent for involvement during pregnancy and medical chart abstraction Women provided written consent for the collection of survey information and biospecimens in each trimester of the pregnancy. In addition, women provided consent for study staff to review their medical charts for specific items related to labor and delivery for the pregnancy. Consent for involvement of the neonate Women provided written consent for the physical examination of the neonate and medical record abstraction on defined variables related to the neonate at delivery (such as gestation age, birth weight, length, defects). Consent for storing biospecimens for future research Women provided written consent to allow stored biospecimens to be used for purposes aside from the main aim of the study (e.g. aside from determination of the primary environmental toxicant). 25 Follow‐up Data Collection of Pregnant Women Communication throughout the study Almost all of the women in our study preferred e‐mail for study‐related communication. Communication e‐mails occurred before the clinic visits in which we hoped to meet the woman to collect a biospecimen (such as urine during each trimester), or an e‐mail to alert (or remind her) that a trimester‐specific survey was available online for her. E‐mail also allowed the study staff to provide other reminders to the participants, such as notifying the labor and delivery staff of their participation as the women’s due date approached. Dropping participants from the study Our study maintained a strong collaboration with the obstetrics clinic. Although the following two items may not be obviously related to the aims of recruiting and retention for a future study, we argue that having these policies in place at the beginning of a study assists in maintaining a strong relationship with the clinic, its administration, staff, and patients. The greater the satisfaction of the clinical partners, the more successful the study may be with recruitment and retention of participants. Women who actively wish to stop participating In keeping with our human subjects approval, women were able to discontinue participation at any time during the study. Once a woman notified the study staff that she no longer wanted to participate, we provided a thank you and best wishes letter. We also noted any reason for her discontinuation in our records. Women who passively stop participating Throughout the pregnancy component of the study, women were approached for survey and biospecimen data. If multiple attempts to contact a woman to complete a trimester‐specific survey or to meet her at a trimester‐specific clinic visit to collect a biospecimen were unsuccessful, we considered this behavior as her passive way to indicate that she no longer wanted to participate. In that situation, the woman would receive a letter notifying her that she had not provided enough data to remain in the study, and that we thanked her for her participation. Women who experience an event that does not allow them to continue participation In the event that a woman experienced an event that would not allow her to participate, the study developed a protocol to acknowledge the event and thank her for her participation to that point. An example might be a pregnancy loss, either spontaneous or induced. This protocol was presented and approved by the human subjects committee. If staff contacted a participant for a study‐related visit or completion of a survey, and the woman notified the study coordinator that she had experienced a loss, the study coordinator would send the woman a letter endorsed by the study staff offering our condolences, wishing her well through her difficult time, and thanking her for her participation. The study coordinator then recorded it in our logs as a censored 26 event due to pregnancy loss. Other events that would lead to this type of letter include moving out of the area or knowing that a woman would not deliver at the affiliated hospital. Summary In summary, this document outlines the procedures that our successful pregnancy cohort employed to recruit and retain 200 women throughout pregnancy to investigate an environmental exposure’s effect on fetal development. Some of our procedures may be relevant only to academic‐medical partnerships, however, as many of the procedural steps are not, nor could be, adapted to meet the needs of a pregnancy cohort developed in a community setting. 27 This page intentionally left blank. 28 SectionOverview:BiomonitoringUpdates
These updates are for information only. Panel members are invited to ask questions and to comment on these projects. Updates  PFC community meeting  Biomonitoring Summit Planning  NCS collaboration  Riverside Birth Study collaboration  Fond du La (GLRI)  Sawtooth Clinic Study 29 This page intentionally left blank. 30 BiomonitoringUpdates
East Metro PFC Biomonitoring Follow‐up Community Meeting Results from the survey analysis portion of this project were mailed to participants on May 1. The mailing included a letter, a 4‐page community report entitled “Survey Analysis: How are participants exposed to PFCs?”, and an invitation to the community meeting. MDH also invited local public health officials, legislators, and other key stakeholders to the meeting and issued a press release about it on May 7. The community meeting went well. Around 40 non‐MDH people attended and were a mix of community members, local public health officials, and media. Jean Johnson presented results from the survey analysis, Ginny Yingling of MDH presented an update on groundwater monitoring for PFCs, and Jim Kelly of MDH presented an update on the PFCs in Homes and Gardens (PIHGs) Study. Presentations were followed by a good question and answer session. MDH held an open house before and after the meeting with more time for individual questions. The project’s web site (http://www.health.state.mn.us/tracking/biomonitoring/projects/eastmetropfc.html) has been updated with a link to the community report and the slide presentations from the community meeting. MDH’s next steps are to provide information on these results to local health care providers and to complete an update to our 2007 analysis of cancer data from Washington and Dakota counties. The updated analysis will include data from 2000‐
2009 and will compare cancer rates in Washington and Dakota counties v. the state and in East Metro zip codes v. the Metro area. The zip code analysis will include new results for kidney and testicular cancer, the two types of cancer identified in the C8 Science Panel’s probable link reports. State Biomonitoring Summit 2013: Sharing Successes and Looking to the Future Given that biomonitoring has become an important tool in public health practice, MDH is holding a summit to convene leaders in state biomonitoring and Minnesota stakeholders to:  Share accomplishments from Minnesota’s biomonitoring program  Learn about key states’ biomonitoring programs and what might be possible in Minnesota; and  Envision the future of biomonitoring in public health improvement in Minnesota. The summit meeting, sponsored by MDH’s Environmental Health Tracking and Biomonitoring program, by MN EPHT, and the Wilder Foundation, will be held on Thursday, June 27th, 8:30 – 3 PM at the Dakota Lodge in St. Paul. 31 In the morning program, speakers from Minnesota, California, Washington, and Wisconsin to describe their groundbreaking state biomonitoring work. Learning about each state’s unique focus, scope, funding, and results will allow participants to consider a wide range of possibilities for Minnesota’s own future. In the afternoon, environmental, public health, and legislative leaders will outline their views on future needs and opportunities for biomonitoring in Minnesota. Summit participants will offer advice to Minnesota’s biomonitoring program about priorities for the future and opportunities to sustain this work. AnyoneinterestedinimprovingpublichealthinMinnesotaisinvitedtoattend
thissummittoexplorehowbiomonitoringappliestootherpublichealthtools,
suchasdiseasepreventionandenvironmentalpublichealthtracking.The
summitbringstogetherforthefirsttimeexpertsinstatebiomonitoring
programs(includingMinnesota’s),policymakers,environmentalprogram
representatives,andmanyothers.
The event is free and will include lunch. A preliminary agenda is available now at: www.health.state.mn.us/summit. The full agenda will be posted on‐line by June 7. Registration
http://www.health.state.mn.us/registration/nocharge/ Registration deadline: June 24 NCS Newborn Mercury Biomarker Validation Supplemental Methodological Study On May 20, 2013, MDH submitted an application for a National Children’s Study (NCS) Supplemental Methodological Study (SMS) to the NCS SMS Team. The application proposes to obtain matched cord blood, maternal blood, and newborn bloodspot samples from the NCS Program Office that were collected from Study participants enrolled by South Dakota State University’s Original Vanguard Center serving Brookings SD, and Yellow Medicine, Pipestone, and Lincoln Counties, MN. Samples will be transferred to the MDH Public Health Laboratory, which will analyze all samples for total mercury, and will analyze cord blood for speciated mercury, lead, and cadmium. Because of concerns about collection methods that may have diluted the cord blood samples, we did not propose to obtain matched cord blood‐cord blood spot samples. We will compare mercury levels in matched maternal blood‐cord blood‐newborn bloodspot samples to assess the relationships between different measures of prenatal exposure to mercury. We will compare newborn bloodspot results to findings from the MDH Mercury in Newborns in the Lake Superior Basin pilot study to help determine whether the elevated levels of newborn mercury exposure seen in northern Minnesota are applicable to southwestern Minnesota and eastern South Dakota. We will also 32 compare these results to those from two other MDH studies: the Pregnancy and Newborns Exposure Study (see summary in this book) and the Riverside Newborn Mercury Project (see update below). Speciation of the mercury in cord blood samples will provide information about likely sources of exposure to mercury, and results for lead and cadmium in cord blood will serve as a comparison to results from the Pregnancy and Newborns Exposure Study. Riverside Newborn Mercury Project The Riverside Newborn Mercury Project is on track. This project, a collaboration with University of Minnesota Investigator Dr. Logan Spector, will analyze total mercury in newborn blood spots collected from participants in the Riverside Birth Study (RBS). RBS participants are a clinic‐based sample of an urban Minneapolis population with a range of incomes and racial/ethnic backgrounds. The MDH Public Health Laboratory has received 160 newborn bloodspot samples from the RBS and analysis will begin this summer. Once lab results are available, we will summarize the distribution of the RBS bloodspots, including the geometric mean, median, and upper percentiles, and the portion of samples > 5.8 μg/L. We will use RBS questionnaire data to determine whether mercury levels differ by babies’ birth season, mother’s self‐reported fish consumption, and other demographic characteristics of the mother. We will compare results to those from the Mercury in Newborns in the Lake Superior Basin pilot study and the Pregnancy and Newborns Exposure Study. Fond du Lac Community Biomonitoring Study Enrollment of participants in the Fond du Lac study is now about 40% complete. Staff mailed study invitation letters to the first batch of potential participants in December 2012. The goal is to enroll 500 participants by the end of October 2013. To date, collection of almost all blood and urine samples from enrolled participants has been complete. Lab analysis has begun, and some results are available. Recently, staff have been working with the study’s Advice Council to determine the best approaches for reporting biomarker results back to participants in ways that are interpretable and meaningful. Great Lakes Sawtooth Mountain Clinic Study The Sawtooth Mountain Clinic Study, funded by the US Environmental Protection Agency (EPA), is an MDH Environmental Health project. The objective is to develop a simple in‐clinic screening and to provide preventive intervention to reduce mercury exposures and promote consumption of fish low in mercury for women of child‐bearing age in a Great Lakes community that includes Native Americans. About 10% of 1,126 Minnesota babies tested in the Lake Superior Mercury in Newborns project were found 33 to have mercury levels above the EPA designated safe level. Newborn exposures are likely to occur when pregnant women consume fish with high levels of mercury. This area has a fishery with higher levels of mercury than elsewhere in Minnesota. The success of the screening and intervention will be validated with sequential mercury and omega‐3 fatty acid biomonitoring. During the first phase of the project, MDH staff have been training health care providers in Grand Marais and Grand Portage, and the study is expected to begin early in 2014. 34 SectionOverview:PFCBiomonitoringGoalsforanExpanded
Sample
In the 2013 legislative session, legislators provided two years of funding to support a third round of PFC biomonitoring in the East Metro. This follow‐up project will ask participants in the earlier biomonitoring projects to take part in a third round and will also expand the sample to include more people from the East Metro, including people who are not long‐term residents. Jessica Nelson will outline plans for the next round of PFC biomonitoring and seeks advice from the panel on goals and methods for measuring PFCs in the expanded sample of the East Metro population. Questions to the panel:  Do panel members have a recommendation as to the stated goal of the expanded sample?  Should children or other special groups be targeted? 35 This page intentionally left blank. 36 PFCBiomonitoringGoalsforanExpandedSample(PFC3)
As recommended by the Advisory Panel, the final Minnesota State budget for FY 2014‐
2015 includes two years of funding for a third round of PFC biomonitoring in the East Metro. This follow‐up project has two components: 1) Re‐contacting participants in the two earlier biomonitoring projects for consent to collect a third blood sample (n=164 for the 2010 project). 2) Expanding the sample to include additional people from the East Metro who are not necessarily long‐time residents (long‐term residence was one criterion for taking part in the earlier biomonitoring projects). The budgetary estimate for this latter group is around 200 people. We are beginning to plan for this next round of PFC biomonitoring and would appreciate Advisory Panel advice and suggestions on the goals for measuring PFCs in the expanded sample of participants (group #2, above). This will help us to decide on methods for sampling the population. Some possibilities for discussion are:  Assess exposures in a representative sample of East Metro residents, including both long‐time and newer residents.  Assess exposures in newer residents of these communities, i.e., people who moved to Oakdale, Lake Elmo, or Cottage Grove after Jan. 1, 2005, when remediation measures were put into place to reduce PFC levels in drinking water.  Respond to legislative interest in measuring PFC exposures in children and in certain potentially vulnerable groups (including farmers in the area).  Some combination of the above. 37 This page intentionally left blank. 38 SectionOverview:NewTrackingContent:ArsenicinPrivateWells
Since 2011, the MDH Well Management Section and MN Tracking Program have been working together to develop and pilot new tracking content for arsenic in private wells. This work included participating in the CDC Tracking Program Private Well Taskforce, which included members from several states and CDC. In March 2013, the Taskforce published new guidance for states interested in developing measures for arsenic in private wells. Taskforce members identified arsenic as a top priority, and also listed several other chemicals of interest (nitrate, pesticides, VOCs). In March 2013 the Taskforce published a white paper with information and recommendations for states that expressed interest in adding private well questions to their state module of the Behavioral Risk Factor Surveillance Survey (BRFSS). BRFSS is a cross‐sectional telephone survey conducted by state health departments with technical and methodological assistance provided by the CDC. States can add questions to the survey for a fee. In the past, MDH has successfully added environmental health questions about private wells (testing), radon (testing), and carbon monoxide alarms to BRFSS, but these questions have not been repeated in recent years. The Taskforce concluded their activities in March 2013, and several members are participating in a new CDC Project Team tasked to implement new measures piloted by the Taskforce on state tracking portals by the end of 2013. Display of these measures is optional, but these efforts help to encourage and promote consistency where possible across grantees in the National Tracking Network. Questions to the panel:  Do panel members have suggestions for improving the display and interpretation of private wells data?  What audiences or partners might be interested in using these data? How?  How might the collection of BRFSS data add value to the piloted measures (to inform public health action)? 39 This page intentionally left blank. 40 SummaryofEvaluationCriteriaforaNewState‐
SpecificTrackingContentArea
ContentArea:ArsenicinPrivateWells
DataSources:WellManagementDatabase(linkedtoCountyWellIndex)
PhaseI:Exploration
Resourcesavailable
Question Is there staff time/interest/expertise? Are there financial and technical resources available? Answer Yes. MN EPHT and the MDH Well Management Section participated in the 2011‐2012 National EPHT Network Private Well Task Force (PWTF), which developed and evaluated data and measures for arsenic and nitrate in private wells. In May 2013, the National EPHT Network approved continuation of the PWTF work, the goals of which are to create displays of the previously developed and piloted private well data metrics, to use these metrics to create vulnerability maps which identify sub‐county areas likely to be at risk from high levels of contaminants in private well water, and to assist public health practitioners at the state and local level to use these maps for public health actions in affected communities. Staff time (in kind) has been dedicated by the MDH Well Management Section. Prevalence
Question Is there a high estimated proportion of the population that is exposed? [OR] Is there a high estimated prevalence of disease or outcome? Answer Nearly 37 million Americans, many living in remote areas outside of the public drinking water distribution system, obtain their drinking water from private wells or other small systems known as unregulated drinking water sources (UDWS).2 About 1 million Minnesotans (approximately 20% of the state’s population) rely on private wells.3 2
Backer, Lorraine C. and Tosta, Nancy. “Unregulated Drinking Water Initiative for Environmental Surveillance and Public Health.” Journal of Environmental Health. 73(7):31‐32. 3
Minnesota Department of Health. Well Management Program. http://www.health.state.mn.us/divs/eh/wells/ Accessed May 17, 2011. 41 The U.S. Environmental Protection Agency (U.S. EPA) regulates the levels of arsenic and other contaminants allowed in public drinking water. The standard for arsenic in public drinking water supplies is a maximum contaminant level (MCL) of 10 micrograms per liter (μg/L). Private drinking water wells are not required to meet federal MCLs or any state standards for arsenic.4 The MCL is based not only on health risks, but also the cost and technical difficulty of removing the contaminant down to that level. While the MDH does not currently have a strictly health‐based value (Health Risk Limit) for arsenic in groundwater, it is likely that a health protective value would be below 10 μg/L (perhaps as low as 3 μg/L). Surveys of U.S. drinking water indicate that about 2% of water supplies exceed 20 μg/L of arsenic.5 A 1994 CDC study (representative sample) of MN private wells indicates 14.7% exceeded 10 μg/L and 35% exceeded 3.0 μg/L. MDH Well Management data from 2008 forward shows that 10.5% of new wells sampled for arsenic levels exceeded 10 μg/L.6 Some groundwater in Minnesota has arsenic as high as 300 μg/L.5 Arsenic can occur in groundwater just about anywhere in Minnesota. Groundwater from the Twin Cities to the South Dakota border, and north along Minnesota’s border with the Dakotas is more likely to contain elevated levels of arsenic. However, arsenic levels can vary from one well to the next, even within a very small area.7 Causality
Question Answer 4
Minnesota Department of Health. “Arsenic in Drinking Water and Your Patients’ Health.” Available at: http://www.health.state.mn.us/divs/eh/hazardous/topics/arsenicfct.pdf 5
Agency for Toxic Substances and Disease Registry (ATSDR). Toxicology Profile for Arsenic. August 2007. 6
Minnesota Department of Health. WELLS database. Accessed January 31, 2013. 7
Minnesota Department of Health. Well Management: Arsenic in Minnesota’s Well Water. http://www.health.state.mn.us/divs/eh/wells/waterquality/arsenic.html/ Accessed May 17, 2011. 42 Is there evidence that exposure is a component cause of adverse health outcomes? [OR] Is there evidence that that the disease has an environmental component cause? The health effects of arsenic depend on its chemical form, how much enters the body, how it enters the body, how long it stays in the body and the unique health status of the person. Inorganic arsenic is fatal at doses much higher ‐‐ 60,000 micrograms (µg) ‐‐ than naturally occurring concentrations in the environment (most people consume about 3.5 micrograms of inorganic arsenic per day from food and water).8 Over time, daily consumption of relatively lower concentrations of arsenic found in drinking water, combined with arsenic naturally occurring in the diet, can cause a number of harmful effects on the human body. Arsenic is not significantly absorbed through the skin, so activities including dishwashing and bathing/showering, are not significant exposure routes.9 Long‐term consumption of drinking water with arsenic levels over 100 μg/L has been associated with health problems including nervous system problems, diabetes, and several circulatory diseases.8 Some studies have now shown that arsenic levels below 100 μg/L may also cause some health problems, including nervous system problems, skin problems, high blood pressure, and reduced intelligence in children.8 The single‐most characteristic effect of long‐term oral exposure to inorganic arsenic is a pattern of skin changes. These include patches of darkened skin and the appearance of small "corns" or "warts" on the palms, soles, and torso, and are often associated with changes in the blood vessels of the skin.7 The U.S. Department of Health and Human Services (DHHS), the EPA, and the International Agency for 8
Agency for Toxic Substances and Disease Registry (ATSDR). Toxicology Profile for Arsenic. August 2007. Minnesota Department of Health. Minnesota Well Management News. “Arsenic Occurrence in Minnesota Wells.” Volume 29, No. 2. Fall 2009/Winter 2010. 9
43 Research on Cancer (IARC) have determined that inorganic arsenic is carcinogenic to humans.7 Long‐
term consumption of drinking water containing arsenic has been linked to several cancers. The most common types of cancers described in reports include cancer of the skin, bladder, lungs, liver, and prostate. Other cancers that may be associated with arsenic in drinking water include cancers of the kidney, colon, bone, larynx, stomach, lymph nodes, and nasal cavities.10 Actionability
Question Are there existing prevention or control programs at MDH or other Minnesota organizations for the exposure or its adverse health outcomes? Answer The national drinking water standard set by the EPA for arsenic is a MCL of 10 μg/L. This standard applies to community water‐supply systems. Although Minnesota Administrative Rules, Chapter 4725, Wells and Borings, requires that new wells must be tested for arsenic and results must be reported to the MDH, there is not an enforceable standard for arsenic in private wells in Minnesota. The MDH Well Management Program notifies all well owners with reported arsenic concentrations that exceed 2 μg/L, recommends that people not consume water with arsenic levels that exceed 10 μg/L, and provides information on re‐testing of private wells and methods for reducing arsenic in drinking water. See information about treatment options in next section below. Minnesota geological data is available to show areas of the state that are vulnerable to elevated arsenic in private well water. A map of vulnerable areas, in addition to the wells data, would help inform outreach and education activities to encourage well testing at the local level. MDH has fact sheets and other information regarding testing on the department’s web site. In addition, the MDH Well Management Section and MN EPHT Program contributed to a new national 10
Minnesota Department of Health. “Arsenic in Drinking Water and Your Patients’ Health.” Available at: http://www.health.state.mn.us/divs/eh/hazardous/topics/arsenicfct.pdf 44 tracking whitepaper that identifies questions about private wells in the Behavioral Risk Factor Surveillance Survey (BRFSS). Data from BRFSS could provide valuable supplemental information about the percent of households using private wells as a primary drinking water source and the percent of wells tested for arsenic over time. Can the level of exposure or disease If the arsenic level in a well exceeds 10 μg/L, the well be modified through policy, owner is encouraged to consider options for reducing regulatory, or personal actions? arsenic exposure, including water treatment, connection to a public water‐supply system, or construction of a new well completed in a different aquifer. There are several types of water treatment systems that can effectively reduce arsenic levels in drinking water. These include special arsenic‐removal media, reverse osmosis with pre‐oxidation, and distillation systems. Is the exposure or disease tied to Healthy People 2020 EH‐20.1, EH‐24 Reduce the global state or federal public health burden of disease due to poor water quality, sanitation, objectives? and insufficient hygiene. Can data and measures in this The data may support the creation of drilling content area be used to develop new recommendations, well construction program initiatives? recommendations, special well construction areas, and public outreach programs. PublicHealthImpact
Question Is the population attributable risk (PAR) or public health impact of exposure known or can it be estimated from available data? [OR] Is the severity of the disease effect known and contributes to mortality or morbidity? Answer The estimates of cancer risk (for lung and bladder cancer alone) associated with arsenic in water at 3 μg/L may be between 4 and 10 additional cases in a population of 10,000.11 This estimate exceeds MDH’s additional lifetime cancer risk level of 1 in 100,000 for calculation of Health Risk Limits. (Initial)Feasibility
Question What are the data sources for exploration of “trackable” indicators? Answer Since August 2008, the Minnesota water well construction code requires all new potable water‐
11
Minnesota Department of Health. “Arsenic in Drinking Water and Your Patients’ Health.” Available at: http://www.health.state.mn.us/divs/eh/hazardous/topics/arsenicfct.pdf. Data from National Research Council. “Arsenic in Drinking Water: 2001 Update”. The National Academy Press. 2001. 45 Does MDH have the legal authority to collect and use the data? supply well (public or private) be tested for arsenic. This requirement generates data for the WELLS database run by MDH Well Management. The reporting level for total arsenic is 2 μg/L, and testing is done by MDH certified labs. Approximately 5,000 to 10,000 new wells are drilled in Minnesota each year. There are 22,000 arsenic sample results in the WELLS database, of which 20,782 are from private water‐supply wells 5. Well contractors also submit to the MDH a well construction record for each new well. Each well record is identified by a unique number and the well information is stored in a PC‐based database system called County Well Index (CWI). CWI was developed by the Minnesota Geological Survey (MGS) and MDH for the storage, retrieval, and editing of water well information. Using the unique well number, arsenic data from the WELLS database can be joined with data in CWI to assess relationships between arsenic occurrence and well location, construction and geology.
In addition, the MDH Well Management Section and MN EPHT Program contributed a new national tracking whitepaper to identify questions that may be appropriate for the Behavioral Risk Factor Surveillance Survey (BRFSS). Data from BRFSS could provide supplemental information about the percent of households using private wells as a primary drinking water source and the percent of wells tested for arsenic over time. MDH has the authority to collect and use the data under Minnesota Administrative Rules, Chapter 4725, Wells and Borings. Most information in County Well Index is entered from the MDH Well and Boring Record, which is submitted by the well contractor to the MDH at the time the well is constructed. Submission of a MDH Well and Boring Record is a requirement of the Minnesota Water Well Construction Code, effective July 1974. Revisions to the rules went into effect on August 4, 46 Are private data classified and protected according to state and federal law? 2008 that required all well contractors licensed by the MDH, and any other person constructing a water‐
supply well for personal use on their own property, to collect a water sample and have it tested for arsenic by an MDH certified laboratory. For collection of testing data through BRFSS, MDH has successfully incorporated questions about private well sources/testing previously in the state module (1994). The WELLS database does not contain 'not public' data. BRFSS data, if available in the future, will not include any personal identifying information. PhaseII:Feasibility
DetailedFeasibility
Question What is the level of quality of the data?  Is it population‐based?  Is it representative of disease or exposure in the state?  Is it reliable and valid? Answer The data is expected to provide a reliable assessment of arsenic contamination in private wells. The population represented by the data is all people being served water from new private wells constructed statewide since August 2008. Because naturally occurring arsenic levels are expected to be relatively stable over time, the results are likely to also be indicative of arsenic levels in existing older wells on an area‐wide (e.g. township or county) basis. Most water samples are collected by the well contractor shortly after completing drilling. Sampling is [ideally] done in accordance with simple straightforward procedures specified by the testing laboratory. Some sampling error is expected. In particular, sediment may be included in samples collected during well development, which may result in artificially high arsenic concentrations. All sample analyses are done by MDH‐certified laboratories using USEPA‐approved analytical methods and having a minimum reporting limit of no more than 2 μg/L. Results are reported as total arsenic. 47 Is there continuity in data collection? Is the data timely with acceptable lag times? Is the data comparable to other jurisdictions? Is aggregation possible at different geographic levels? What is the cost to MDH to obtain data? BRFSS questions are routinely tested prior to implementation, and the data are derived from a representative sample of the state’s population. Arsenic sample collection and analysis for all new water‐supply wells has been required by rule (Minnesota Rule, Chapter 4725) since August 2008 and will continue for the foreseeable future. Samples are collected immediately upon completion of well construction and analytical results reported to the MDH within 30 days. Data is entered into the MDH database within a day or two. Data summaries/updates are likely to be provided annually within 60 days after conclusion of the annual cycle. Standardized USEPA analytical methods for total arsenic are used nationwide, so data should be comparable to other well water data in other jurisdictions. Data is collected at discrete points (wells) with location information, so can be aggregated statewide and at county, township, zip code and other local or regional levels. Data is generated and submitted to MDH at no cost to MDH. Costs are incurred for staff time to enter data and analyze and summarize data. 48 *Pilotthedata*
Years of data piloted: 2008 (August‐December), 2009, 2010, 2011, 2012, 2013 (January) Geographic trends  o the number and percent of new private wells that exceed 10 μg/L arsenic, by county o the percent of new private wells that exceed 10 μg/L arsenic, by aggregated township area o the number and percent of new private wells that exceed 2 μg/L arsenic, by county o 95th percentile arsenic concentration, by county o Median arsenic concentration, by county o the number and percent of new private wells by arsenic concentration (μg/L) by year Measures still under development/evaluation  Vulnerability index (map) of arsenic in private wells by county (based on geological data)  The percent of population using private wells as a primary drinking water source (BRFSS, starting in 2014 with three year increments)  The percent of private wells tested for arsenic (BRFSS, starting 2014 with 3 year increments) 49 50 51 52 53 54 Temporal trends Note: Naturally occurring arsenic is relatively stable in the environment and is not expected to change significantly over time. Changes may be expected in the future if well construction/completion methods that reduce arsenic concentrations in new wells are identified and put into practice. Percent of new private wells by arsenic concentration range by year Percent of Sampled Wells with Arsenic Concentration of: YEAR Number of Wells Sampled 2008 2942 58.8 32.4 8.8 2009 4717 55.9 32.6 11.5 2010 4421 55.2 34.2 10.6 2011 4149 50.4 38.8 10.9 2012 4196 50.0 39.6 10.4 Total 20425 53.9 35.6 10.6 <=2 µg/L >2, <=10 µg/L >10 µg/L Percent of New Private Wells with Arsenic > 2 ug/L, by Year
Percent of Wells Sampled
60
50
40
30
Arsenic >10 ug/L
20
Arsenic >2, <=10 ug/L
10
0
2008
2009
2010
2011
2012
Year
55 This page intentionally left blank. 56 57 Regional Arsenic and Geology The arsenic data is based on analysis of 3200 data points representing Public Water Supply raw water. 58 PhaseIII:Recommendation
EmergingIssues
Question Is the degree or level of exposure changing or perceived to be changing? [OR] Is the incidence or prevalence of disease changing or perceived to be changing? Answer The level of exposure has probably remained fairly constant. It is possible that the level of exposure has decreased since required testing began in 2008, due to well owner awareness of arsenic concentrations and health risks, and resulting installation of water treatment systems. PotentialforInformationBuilding
Question Is this a hazard with unknown associations to health outcomes or unknown level of exposure in the population? [OR] Is this a disease with unknown environmental etiology or unknown prevalence? Are there other programs at MDH that would be interested in this content area? Answer Exposure to arsenic has many known adverse health outcomes. Exposure is estimated based on population using private drinking water wells. Unknown OutsideInterestorPublicConcern
Question Is there a high concern regarding the proportion of the population exposed to the hazard? [OR] Is there a high concern regarding prevalence and etiology of disease? Is the exposure or disease a priority that has previously been identified by environmental health organizations? Would this content area utilize existing datasets in a new way? Answer The proportion of the population exposed to arsenic in private drinking water is unlikely to have increased in recent years. Healthy People 2020 includes an objective to reduce exposure to arsenic. The dataset is currently not generally accessible to the public or other state or local government agencies. Presenting the data metrics on the MN EPHT data portal would make the data available to all interested parties through interactive charts and maps. Balanceamongcontentareas
Question Answer Is there balance between This content area adds value by including hazard/exposure and disease content additional environmental hazard data to the 59 areas tracked? Is there balance between age groups affected among content areas tracked? portal. Currently, water data on the portal is limited to community water systems. N/A EconomicImpact
Question What is the economic impact on MN EPHT Program and partners of adding this content area (e.g. state, healthcare systems, industry)? Answer Individuals and local governments likely will have some economic impacts through additional water testing (voluntary). However, the economic impact of adding this content area is expected to be minimal. The Well Management Section and MDH will experience efficiencies through MN EPHT communications and outreach activities that promote data portal use (generally) to local agencies and the public. 60 SectionOverview:TrackingUpdates
These updates are for information only. Panel members are invited to ask questions and to comment on these projects. Updates  New Data Available at MN Public Health Data Access  MN Community Environmental Health Profiles (Information by Location)  CDC Project Teams Update & Workshop 61 This page intentionally left blank. 62 TrackingUpdates
New Data Available at MN Public Health Data Access Minnesota Public Health Data Access is updated and maintained by the MN Environmental Public Health Tracking Program (MN Tracking Program) under a cooperative agreement with the Centers for Disease Control and Prevention. New Colorectal Cancer Data In Minnesota, colorectal cancer is the third most common cancer diagnosis among males and females and the second leading cause of cancer‐related deaths. To view data on the incidence of colorectal cancer in Minnesota, see: Colorectal Cancer: Facts & Figures, newly added to the Minnesota Public Health Data Access portal. You can also generate custom data tables using the Cancer Data Query. Data on the incidence of colorectal cancer in Minnesota can be used to evaluate the effectiveness of cancer prevention initiatives, such as colorectal cancer screening. Increasing colorectal cancer screening is one of the objectives found in the Minnesota Cancer Alliance's Cancer Plan Minnesota 2011‐2016. More Minnesotans die of colon and rectum cancer than either breast or prostate cancer. Improvements in colorectal cancer screening enable the screening physician to find and remove polyps before they develop into cancer. Screening also identifies cancers earlier when the disease is easier to cure. Minnesota Public Health Data Access is updated and maintained by the MN Environmental Public Health Tracking Program (MN EPHT) under a cooperative agreement with the Centers for Disease Control and Prevention (CDC). MN EPHT developed these pages in collaboration with the MN Cancer Surveillance System. Poverty and Income Data Data on Poverty and Income for the state of Minnesota are now available on Minnesota Public Health Data Access. On these new pages, you can view interactive charts on poverty by year and age, childhood poverty, and median household income. People living in poverty experience higher rates of some diseases, and research shows that low socioeconomic status increases the chance that a person’s health is threatened by environmental conditions. People living in poverty are more likely to live in areas with poor quality housing, have less access to healthy foods, or live in close proximity to traffic and crowding, all of which affect public health. 63 Asthma Emergency Department Visits In May, to coincide with World Asthma Day, the MN Tracking Program launched new nationally consistent data and measures for asthma emergency department visits. These data complement existing portal measures for asthma hospitalizations. Currently, the asthma ED data on the portal can be seen on the Facts and Figures page (charts) and as displays of asthma trends over time. County‐level data can be viewed and downloaded through a customizable query. View data at: https://apps.health.state.mn.us/mndata/asthma_ed Coming Soon: MN Community Environmental Health Profiles The MN Tracking Program is developing new community environmental health (EH) profiles for Minnesota Public Health Data Access. When this feature is implemented in summer 2013, users will be able to select a county and print and download a profile of multiple indicators (e.g., asthma, air quality, cancer, lead poisoning, poverty and income). These profiles will include county and state comparison values with notes about the data. The CDC National Tracking Network has established a national project team dedicated to a parallel effort with several grantee states participating, including Minnesota. Lessons learned from others will be gathered and shared across the Network. See new CDC project teams below. Currently, the MN Tracking Program is demonstrating prototypes of community EH profiles with local health departments in MN, so as to gather comments and suggestions about the design, content, and IT requirements. The program is also evaluating other examples of profiles of county‐level data at the state and national levels (e.g., County Health Rankings, MN Compass) to ensure that the new profiles add value to existing sources of data or profiles. The profiles will initially focus on MN Tracking Program indicators at the county level, with the potential to expand to sub‐county data and additional indicators beyond tracking, depending on available data, resources, and interest among data users and partners. Increasing Spatial Resolution of Portal Data The MN Tracking Program is evaluating areas where portal data can be provided at a finer spatial level to inform public health action. Developing and maintaining these data is a resource‐intensive task, so staff are identifying priority areas where it is feasible and useful to provide data at finer geographic scales (region, county, zip code, census tract). One priority area, identified in collaboration with the MDH Asthma Program, is zip‐code‐
level emergency department (ED) data for the Twin Cities 7‐county metropolitan area. 64 Because data users (e.g., the MN Pollution Control Agency, school nurses, state legislators, communities) often request asthma data, adding these data to the portal would make it easier for people to access the data directly (on‐line) . The MN Tracking Program anticipates adding zip‐code asthma ED data to MN Public Health Data Access by July 2013. We are also identifying other priority areas where finer spatial resolution data could be used to inform local public health action. Although this effort involves challenges, such as periodic changes in geographic boundaries (zip codes) over time, protecting data privacy, and ensuring data quality, increasing spatial resolution of data is one area where the Tracking Network (state and national) can add value. New CDC Tracking Project Teams & July Workshop The CDC National Tracking Network has established 7 new national project teams to focus on tracking data use and increasing national Network visibility. Each project team includes grantee/state staff with expertise in communications, science, and informatics. Teams are charged with developing concrete products (profiles, toolkits, maps) that will be made available and promoted through the National Tracking Network. The timeline for these projects is from May to December 2013. The MN Tracking Program staff is participating in four of these project teams, with calls taking place periodically: 1. Health Impact Assessment (HIA) Toolkit: This project will develop a toolkit of indicators, case studies, and resources to demonstrate how tracking data can be used in Health Impact Assessments. The goal is to make the data easy to find and use to inform HIAs and to inform community‐level decision‐making. The toolkit will be posted on CDC’s web site, and promoted through the National Tracking Network. In Minnesota, asthma, COPD, and childhood lead poisoning data have been used in some Health Impact Assessments. The MN Tracking Program is working closely with the Health Impact Assessment Program at MDH to solicit advice and suggestions from local communities about the tracking data (indicators) and data formats or displays that would be most useful for HIAs. For more information about HIAs and promoting health in all policies, see the MDH web site: Health Impact Assessments. 2. Community Environmental Health Profiles: This project will provide profiles or reports that communities, local health departments and coalitions, and other stakeholders can use to assess and monitor environmental health issues over time to drive policy, interventions, and other public health actions. Community profiles will combine environmental and related health measures into community‐specific reports that can be easily accessed and downloaded. Some example profiles have been developed and implemented by state tracking 65 programs, including Wisconsin, Florida, and Maryland. For additional information related to activities that are already underway in Minnesota, see MN Community EH Profiles (above). 3. Economic Burden of Disease in Children: Recent national and international reports have documented that the U.S. lags on many important indicators of child health compared to other developed countries. Environmental diseases place a large burden on children, including costs in medical care and quality of life. The project goal is to produce a state‐specific report on the economic burden of childhood environmental disease. The first step will be to examine 4 conditions: Childhood asthma, childhood lead poisoning, childhood neurological diseases, and childhood cancer. 4. Mapping of Risk Areas for Private Well Contamination: This effort aligns with collaborative ongoing efforts of the MDH Well Management Section and the MN Tracking Program to develop and pilot new measures for arsenic in private wells (planned by the end of 2013). This project will 
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Create and display private well data metrics that were piloted by the national Private Well Taskforce; Use these metrics and similar metrics associated with US Geological Survey modeling to create vulnerability maps that identify sub‐county areas at risk from high contaminant levels in private well water; and Assist public health practitioners with using maps to inform public health actions. National CDC Tracking Projects Workshop In July, MN Tracking Program staff will participate in a national Tracking workshop for grantees in Atlanta, GA. The workshop will enable project teams to meet face‐to‐face to work on updates, implementation, and collaboration. The MN Tracking Program will provide an update about the outcome of this workshop and projects at the September Advisory Panel meeting. 66 SectionOverview:OtherInformation
This section contains documents that may be of interest to panel members. 
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2013 Upcoming Advisory Panel Meeting dates March 2013 Advisory Panel Meeting Summary Advisory Panel Roster Biographical Sketches of Advisory Panel Members Biographical Sketches of Staff Environmental Health Tracking and Biomonitoring Legislation 67 This page intentionally left blank. 68 2013AdvisoryPanelMeetings
Tuesday, June 11 1–4 pm The June meeting will take place at: The American Lung Association of Minnesota 490 Concordia Avenue St. Paul, Minnesota The September meeting will take place on Tuesday, September 10 1–4 pm Venue to be determined. 69 This page intentionally left blank.
70 Summary:March12,2013AdvisoryPanelMeeting
Advisory Panel: Bruce Alexander, Alan Bender, Jill Heins‐Nesvold, Pat McGovern, Geary Olsen, Greg Pratt Steering Committee: Jeanne Ayers, Aggie Leitheiser, and Joanne Bartkus MDH: Jean Johnson, Jessica Nelson, Mary Jeanne Levitt, Chuck Stroebel, Jeannette Sample, Matthew Montesano, Paula Lindgren, Blair Sevcik, Barbara Scott Murdock, Rita Messing, Carin Huset, Paul Swedenborg. Welcome and introductions Bruce Alexander, chair, welcomed panel members and attendees and invited them to introduce themselves. Legislative update Aggie Leitheiser gave the legislative update. Biomonitoring has garnered a great deal of interest in the legislature, and four bills have been introduced: 1) SF1170/HF097 would “address environmental health risks.” Part of the Omnibus environment bill includes the MPCA‐MDH initiative for biomonitoring, which is in the Governor’s budget. The legislature’s environmental fund, which has funded EHTB since 2007, would also fund this initiative. 2) A second bill introduced in the House (HF0961) would provide funding from clean water funds (the Legacy fund) “to establish a biomonitoring program that would focus on children and disadvantaged communities to provide data on disparities in pollutant exposure and other measures necessary to assist with water quality management and protection decisions.” 3) HF1402/SF785 would provide $313,000 per year to continue PFC biomonitoring in the East Metro, in accordance with the recommendations of the EHTB Advisory Panel. 4) HF994 would specify that “the MPCA may not issue or modify a permit to a facility without analyzing and considering all the cumulative levels and effects of past and current environmental pollution from all sources on the environment and population of the geographic area… within which the facility’s emissions are likely to be deposited.” The above bills provoked some lively discussion. Aggie reminded the panel members that both they and MDH had chosen mercury in children as the analyte of choice for further biomonitoring in Minnesota—because we can take action to prevent exposure to this chemical, which has known health effects. Greg Pratt noted that the language in House bill HF994 is already in law for the Phillips neighborhood. He observed that the requirements would create a lot of work for the MPCA, yet the bill does not appropriate any money to do the work. So far, Aggie said, the bill has not been heard and has no Senate companion. 71 Pat McGovern asked, which analytes are mentioned in the HF0961 bill? Jean answered that this bill appears to be based on our report to the legislature, as it addresses some of the analytes we had listed. Both Aggie and Jeanne Ayers asked whether the panel would recommend studying PFCs instead of mercury in the legislative initiative. The panel’s response was no. Aggie said that we hope to get some flexibility with funds [so we could add PFCs]. Geary reminded the panel that the original recommendation about PFCs in the report to the legislature had posited two studies: the first would create an update to the original East Metro project, and a second would recruit and biomonitor a larger population in the East Metro. He asked, can we prioritize one of these two? He added that, in his opinion, we have two studies that followed the same group of individuals, and it would be better to establish the trend in those people. If we have money for only one PFC study, EHTB should do the longitudinal study. Panel members agreed. Pat McGovern asked, would a PFC study trump the mercury study? Geary answered: No. Alan Bender added that, although a second longitudinal PFC study would be of interest, mercury is a much higher priority. Little is known about mercury’s distribution in the population, he said, and the mercury data could mean that something far more significant is going on that we don’t understand. Given the nature of that exposure, mercury trumps PFCs. Bruce reinforced the message by saying, mercury has known public health effects. Air Quality, Health, and Traffic Paula Lindgren and Greg Pratt presented a report on an MDH, MPCA, and Rochester Epidemiology Project (REP) Partnership study of asthma exacerbations and traffic in Olmsted County, Minnesota. The REP links medical records of Olmsted County residents with the sources of their medical care, and facilitates access to medical records from multiple institutions. The REP data, from 1.8 million medical records on nearly 1 million people, provide a complete picture of all health care delivered to each individual in that population. This study gathered data on all medical visits for asthma treatment from 2000 through 2010: inpatient hospitalizations, emergency department visits, and three or more outpatient visits for asthma. For each patient, the total number of asthma exacerbations was divided by the number of years in the REP during that 11‐year period and recorded. Each patient’s address was geocoded to its exact location and the patient’s age and gender were also recorded. Altogether, 19,915 people with asthma were in this study (Table 1). These people with asthma exacerbations were then mapped to see whether asthma exacerbations were correlated with traffic, measured as vehicle kilometers traveled (VKT) within 250 and 500 meter buffers around the address or as traffic density. 72 Table 1. Exacerbations among REP Asthma Patients Exacerbations per Year N % None 16,218 81.44 1‐3 3,664 18.40 4‐6 28 0.14 7‐9 3 0.02 10‐12 1 0.01 > 12 1 0.01 Table from Lindgren/Pratt presentation. Because many components of traffic can affect human health, Greg Pratt explained, we don’t know which air pollutant, or other component of traffic, is responsible for adverse health effects. So this study took the perspective that traffic is harmful as a result of the integrated effect of multiple components. We looked at exposure to traffic itself, using methods for systematically generating a highly spatially resolved measure of traffic density. Once we have quantified exposure to traffic, Greg continued, we can use that metric to evaluate factors that may be associated with traffic, such as asthma, socio‐economic status, racial/ethnic composition, and measured or modeled pollutant concentrations. The metric can also be used in a land‐use regression model to estimate pollutant concentrations. This analysis is based on studies that showed that concentrations of many pollutants found along busy roads decrease to local urban background concentrations at about 300m from the roadway. The study then looked for associations between traffic exposure and the number of asthma exacerbations/year. Poisson models were used for average exacerbations and logistic models were used for binary outcomes (any exacerbation/no exacerbation). The data showed that the average number of asthma exacerbations per year increased as traffic density increased. Results from the logistic model showed that the odds of any exacerbation increased 8% for every unit increase in traffic density, after controlling for age, gender, and poverty. The odds also increased with each unit increase in vehicle kilometers traveled: 12% for people living within 250m of the roadway and 6% living within 500 m of the roadway. But another measure is also strongly associated with asthma: poverty. To measure this, staff constructed a block group for each geocoded address and examined the income to poverty ratio for each block group. (Note: The calculation uses the income levels defined as poverty thresholds by the federal government.) Families and individuals who are identified as having income below the poverty level have an income‐to‐poverty ratio of less than 1.00. In this study, the percentage below 1.0 in the block group was assigned to each person with asthma exacerbations in the block group. The analysis looked at any exacerbation or at the number of exacerbations with respect to age, sex, poverty, and traffic density and VKT. The data showed that the odds ratio for asthma 73 exacerbations associated with poverty increased 600% (six‐fold) for every unit increase in poverty, after adjusting for age, sex, and traffic. Discussion Much of the discussion revolved around other health and socioeconomic status (SES) indicators that might be added to the analysis. Pat McGovern commented that on the West Coast, studies looking at exposure to traffic have seen similar associations with preterm birth, which is also associated with poverty, especially for African‐Americans. Paula thought that would be a good idea, but explained that pre‐term birth data are available at the county level only. Bruce asked whether birth certificate data had location data, and Jeanne Ayers suggested that the REP might have vital records with fine geographic resolution. Jill asked, why not look at COPD as an outcome? Given that particulates from traffic affect people with COPD at the molecular level, we would expect a stronger COPD association with traffic pollution than with asthma. Traffic pollutants act more as irritants for asthma. Although staff had made the decision based partly on the fact that COPD is harder to document in medical records than asthma, Paula said she would be interested in looking at COPD. Aggie asked whether being poor means a higher risk of asthma, or whether it is a matter of where you live. Paula explained that it is a little of each. Jill asked about the estimate of 300m as the extent of bad air quality near highways, and Greg answered that earlier studies had shown that pollution levels decline to background between 200‐
400m from the roadway. Bruce asked whether an urban/rural analysis would be possible, one that might compare Rochester to everywhere else in Olmsted County. He suggested that people in urban and rural environments might encounter very different exposures. Paula replied that an urban/rural indicator might be possible. In addition, Bruce noted, some significant changes in demography have taken place in Rochester over the last decade, as many more immigrant populations—Hispanics and Somalis—have come to Rochester, according to 2010 data. Including race/ethnicity in the model could make it possible to identify disparities in exposure and target interventions to reduce exposures. This led Pat to ask whether staff had considered race as a covariate. Greg replied that staff could pull racial/ethnic data from the census, but that adding such data might cause the model to lose statistical power. 74 The panel also suggested examining housing as another indicator of SES suggested for examination, but staff explained that, although the REP contains a housing index based on age and housing type, 50% of the data were missing. Population Characteristics In a related presentation, Blair Sevcik reviewed new Minnesota‐specific Tracking indicators of population characteristics that describe… 
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People in Poverty Median Household Income People without Health Insurance She used data from the U.S. Census Bureau’s Small Area Estimates Program, including the 2005‐2009 Small Area Health Insurance Estimates (SAHIE) and the 2000‐2010 Small Area Income and Poverty Estimates (SAIPE) and determined poverty by comparing household income to federal household poverty thresholds. These thresholds are determined by the U.S. Census Bureau and calculated using a family's household size and composition. If a household’s income (the sum of incomes from everyone living at the address) is less than a poverty threshold, then every person living in that household is considered to be in poverty. People without health insurance have neither private nor public (government) insurance. In demonstrating the data, Blair pointed out the increase in poverty in Minnesota. She noted that the poverty rate in 2010 was 12%, 4% higher than in 2000, but also explained that the method for calculating poverty had changed substantially between 2004 and 2005. Thus, this rising trend should be interpreted carefully. Moreover, although 12% of Minnesotans of all ages were impoverished in 2010, 15% of all Minnesota children under age 18 and 17% of those under age 5 lived in poverty. Overall, childhood poverty in Minnesota has trended upward since the year 2000. In the same time frame, median household income in Minnesota had been trending upward until 2008, when it began to decline. Nevertheless, median household income in Minnesota has been consistently above the national average since the year 2000. Health insurance coverage in Minnesota has been relatively stable since 2005, with a small increase in the percentage of people without health insurance in 2009‐10. Again, Blair cautioned, this trend must be interpreted with caution because of a substantial change in methodology between 2007 and 2008. In 2010, about 10% of Minnesotans under 65 years of age and about 7% of children (18 years and younger) had no health insurance. Analyzed by race/ethnicity from 2005 through 2010, the health insurance data show that non‐Hispanic whites without health insurance were consistently around 8% of the population compared to about 15% for non‐Hispanic blacks until 2009‐2010, when the uninsured rate rose to about 16%. Minnesota’s uninsured Hispanic population, however, has hovered around 27‐28% throughout the entire period. 75 Questions to the panel requested recommendations for: 
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Other measures to link Other data users Other indicators Discussion Pat McGovern suggested looking at employment (yes/no) to see how it correlated with poverty and income. She suggested contacting the Minnesota Department of Employment and Economic Development (DEED) for data. Greg asked whether the median income was in constant dollars, and Blair explained that the SAIPE database uses only unadjusted income numbers. Noting that the race/ethnicity slide for lack of health insurance may reflect a big change in demography in Minnesota, Bruce commented that it would be good to show the number of people in each racial/ethnic category together with the percentage of uninsured in each group. Are we seeing changes in the numbers of uninsured people with a rising Hispanic population? Hispanic immigration is changing age distribution in Minnesota, especially in rural areas. Alan asked whether the public would understand why we consider poverty, income, and health insurance to be environmental. Traffic is an environmental issue that people can understand, but while the professional world would understand why we looked at traffic, the public might not understand why we’re looking at poverty. Greg replied that people in the Phillips neighborhood—a disadvantaged neighborhood—are surprisingly sophisticated about the many things that affect health, adding that the language in one of the House bills described above (HF994) illustrates this. He also commented that it’s not good for society to have young kids growing up in poverty. In response to the discussion of other variables, Pat suggested, first, that education level may affect people’s ability to get access to healthcare and, also, that the Tracking program might consider health insurance’s association with emergency department (ED) visits. Jill added that public programs have found that uninsured people have the highest rates of ED visits. Pat asked whether Tracking had any data on homelessness. When Blair asked about sources, Jill suggested Wilder Foundation, which has done regular surveys of homelessness statewide. Using housing age came up as a possible measure of poverty, and Greg Pratt noted that the cities have categorized housing, denoting some as distressed housing. He suggested contacting Cecelia Martinez at the Center for Earth, Energy, and Democracy (CEED) and also noted that housing built in 1950 is more likely to contain lead paint. Bruce suggested that it would be interesting to look at asthma rates over time in Olmsted County, especially as demographic changes take place in the population and as asthma definitions change. 76 Tracking Updates Jean Johnson reviewed the update about the CDC Tracking Network’s solicitation of “data use” project proposals. CDC has asked Tracking grantees to submit proposals for short‐term projects that explore data presentation and impact analysis, apply innovative informatics techniques, and publicize highly relevant results or products. The agency’s areas of interest include the use of: 
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Sub‐county data, such as zip code level data; Environmental health profiles (multiple exposures and impacts, making effective policies);  Place‐based decision making;  Social vulnerability indices;  Private well data. Minnesota is interested in proposing a place‐based analysis project and a private wells project focused on arsenic. In choosing projects, CDC aims to highlight and promote the use and relevance of Tracking work by demonstrating how Tracking is a unique, valuable resource. Discussion Bruce asked for some clarification on the review process for the proposals, and Jean explained that these proposals do not provide extra funding for the grantees. The money for the projects comes from existing grant money, which is currently from the Affordable Care Act, and the projects are a redirection of existing resources, rather than new resources. Greg suggested that staff get in touch with Cecelia Martinez, who works on similar multiple variable issues using EPA tools, such as EJ (Environmental Justice) View and EJ Screen, at the Center for Earth, Energy, and Democracy (CEED). He also suggested Jeff Matson at the University of Minnesota’s Center for Urban and Regional Affairs (CURA). Bruce commented that pulling together multiple indicators sounds similar to network analysis projects happening at the U. Chuck Stroebel then highlighted updates on the MN EPHT website and called attention to two recent successes: 
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Collaboration with MN Cancer Alliance to develop a press release about ways to prevent melanoma. The press release used MN EPHT data to illustrate the rise in melanoma among adults aged 20‐49 years. Collaboration with the American Lung Association‐Minnesota to produce a joint publication, The Scope of COPD, which lists various ways people can prevent chronic obstructive pulmonary disease and uses MN EPHT data to illustrate facts about COPD. 77 The East Metro PFC Biomonitoring Follow‐up Project: Results from Survey Data Analysis Jessica Nelson and Christy Rosebush presented the preliminary results of the questionnaire analysis portion of the East Metro Follow‐up Project. Jessica began by briefly describing the scope of the project, which in 2010 measured the concentration of perfluorochemicals (PFCs) in 164 East Metro residents who had participated in MDH’s 2008 pilot project. The Phase 1 analysis of the follow‐up, now complete, measured the 2‐year change in PFC concentrations among project participants. The Phase 2 analysis is studying participants’ survey responses to investigate sources of exposure to PFCs. The 2008 project had gathered limited information on participants. Thus, Jessica said, the 2010 project questionnaire was designed to gather more detailed information on residential and water consumption history. This enables staff to construct a better measure of each participant’s exposure to PFC‐contaminated water and―poten ally―a range of other sources of PFC exposure reported in earlier studies. She then described how staff derived four variables related to residential history and water consumption based on questionnaire responses: 
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Total time lived in the three communities12 Total time in which participants drank unfiltered water Type of water treatment at the 2008 address Tap water consumption Jessica then reviewed the data (tables and graphs in March 2013 Advisory Panel book) and summed up the findings for water consumption and residence in the community. Overall, the longer participants had lived in the community and the more years they had spent drinking unfiltered water, the higher their PFC levels. Analyses of total years residing in the community and total years drinking unfiltered water showed a clear rising trend in PFC levels, which was somewhat stronger for the years of drinking unfiltered water. People who used reverse osmosis or granulated activated charcoal filters had the lowest geometric mean PFC levels. People who did not treat their water at home had the highest, while people who used bottled water or pitcher/refrigerator/kitchen filters had levels in between. But because the survey question asked about only one point in time, these results are difficult to interpret. Finally, Jessica said, the analysis had also shown a strong positive association between serum PFCs and current tap water consumption, reported as number of cups/day. People who reported drinking 0 to 2 cups of tap water/day had about half the geometric mean for PFOA compared to those who drank 3‐6 cups/day and those who drank 7 or more cups/day. She said that this likely indicates that current consumption reflects a person’s past consumption. We do not want to convey the message that current tap 12
People in the study area were fairly mobile within the three communities. Thirty‐nine percent of participants had two different addresses in Oakdale, Lake Elmo, or Cottage Grove, 15% had three addresses, and 7% had four or more addresses. 78 water is a significant source of exposure to PFCs, she added, so we need to think carefully about how to present this. All analyses were adjusted for age, gender, and blood donation. Jessica then discussed blood donation, product use, and home garden variables. The survey had asked whether participants had donated blood in the last 2 years and how frequently they donated blood each year. Despite the small numbers, the analysis showed that the people who had donated blood in the last 2 years had significantly lower PFC levels compared to those who had not, and that people who donated frequently (3+/year) had lower levels than those who donated only 1‐2 times/year. The results from questions about product use and home gardens were mostly null for the three PFCs of interest: PFOS, PFOA, and PFHxS. Participants who reported having new carpets installed in the last year before the follow up project (2009) had higher blood levels for these three PFCs, but the results were not statistically significant for PFOA and PFHxS. Participants who reported using waterproof spray had statistically significant lower levels of PFOS and PFOA. PFC levels did not differ between people who had home gardens and ate homegrown produce, and those who didn’t. Christy Rosebush reported the results from the survey’s food frequency questions. The literature on PFCs had suggested that certain foods, fast food, and fast food or snack packaging contributed to PFC levels, so the survey contained many questions about diet. The questions emphasized products with food contact packaging. The analysis, however, did not find any associations between PFC levels and eating fast foods frequently or eating microwave popcorn and other foods that come into contact with packaging, nor did it find associations with eating foods such as red meat and potatoes, which are suspected as sources of exposure to PFCs. Jessica then handed out two supplemental tables of preliminary results and presented a slide of the first, the 2010 results for exposure to PFBA, a PFC detected in only 21% of participants. PFBA is widely detected in water sampling in the East Metro, and has a much shorter half‐life (several days) than the other PFCs discussed. •
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Likelihood of PFBA detection increases with age Groups less likely to have PFBA detected included females (OR=0.48) and people who donated blood (OR=0.31) There was no association with whether or not a person had a home garden, but frequent eaters of home garden produce were more likely than never eaters to have PFBA detected (though this was not statistically significant) People whose carpet and furniture were treated for stain resistance prior to 2002 were more likely to have detectable PFBA The results were not different by community 79 She next presented a slide of the second supplementary table, which summarized the data from people whose PFC levels did not decline from 2008 to 2010. People who had lower PFC levels in 2008 were more likely to be in this group, and people who donated blood were less likely to be in this group. There was no evidence of any associations with home garden produce, years drinking unfiltered water, sex, or age. There were some positive associations with product use, but these were not statistically significant. Jessica then summarized the preliminary conclusions: •
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Total years drinking unfiltered water best predicts serum PFCs Current tap water consumption reflects past consumption habits This evidence supports the conclusion that drinking water was a major source of exposure in the community and that efforts to reduce this exposure were key in reducing serum levels Serum PFCs are lower in people who donate blood A positive association may exist between PFOS, PFOA, PFHxS, and new carpet Lack of positive results with other products or diet variables could be due to the small sample size and the fact that this population was highly exposed to PFCs in their drinking water in the past. PFBA was more likely to be found in people who were: o male, older, frequent home garden produce eaters, not blood donators, and/or had pre‐2002 stain resistant carpet treatment • People whose PFC levels did not decrease from 2008‐1010 more likely to: o have had lower 2008 levels, not donate blood Jessica ended by summarizing the next steps for the project:  Finish the data analysis and interpretation;  Report results to the participants by letter;  Hold meetings with the community and with healthcare providers in the community;  Submit manuscript of the results to a journal. Discussion Greg Pratt asked whether we know how effective different water filtration methods are. Jessica answered that MDH has studied the effectiveness of water filtration methods in removing PFCs. All of the types mentioned can filter PFCs. The results presented categorized the type of water treatment at participants’ 2008 address based on the likelihood of consistent, effective filtration. 80 Jessica asked the panel: Would the panel recommend a combined variable using years of drinking unfiltered water and current tap water consumption (as a surrogate for past consumption)? Bruce’s question was: What are you trying to answer? Jessica said that the intent is to create a predictor variable that best reflects past exposure to PFCs through drinking water. This combined variable would incorporate both length of time of exposure and quantity of exposure. Geary Olsen said that the survey question should have asked about tap water drinking habits in the past. Earlier, he had commented that the three tap water consumption categories presented really appeared to be two groups—people who don’t really drink tap water and people who do—and suggested that Jessica analyze a binary classification, with 0 to 2 cups per day compared to 3 cups or more per day. Bruce, on the other hand, thought that displaying the water consumption data in finer categories would be instructive. But he did not think the suggested combined variable (i.e., combining years of drinking unfiltered water and current tap water consumption as a surrogate for past consumption) would be helpful either for analysis or for conveying a clear message to the community. Greg commented that he didn’t see why we shouldn’t combine these variables, but he, too, was unsure that the new metric would be more useful. If current water consumption is linked to PFC levels, he said, and if no PFCs are in the drinking water anymore, then current consumption of water does relate to past exposure. But Jessica quickly pointed out that the filtered drinking water still has some low PFC levels, although nothing like the PFC levels in the past. Alan’s comment on the discussion was that, in considering how to present these data, it is important to determine whether the message is aimed at the community or at publication in a peer‐
reviewed journal. Jessica asked: Do panel members recommend additional analyses for the phase 2 analysis? Geary Olsen suggested that Jessica should be very cautious in interpreting any relationship between PFBA laboratory data and any possible sources of exposure identified by questionnaire. Saying that it is a widespread, poorly understood contaminant, he explained that low levels of PFBA are found in many different sources, not just in water, and it’s unclear what they are. Pat asked, are you saying that PFBA is ubiquitous in the environment? Yes, he answered, in numerous ways. In addition, it has a very short half‐life—about three days—so it leaves the body quickly. For this reason, he advised against the logistic regression (detection vs. non‐detection) analysis, but instead recommended showing actual values for PFBA. Overall, because of the number of sources and the short half‐life of the chemical, Geary believes that the analysis presented is uninterpretable. He suggested talking to Bill Reagan of 3M about the difficulties in analyzing PFBA. 81 The panel recommended no additional analyses for this project, and Jessica asked: How should MDH interpret these results for participants and the community? In reviewing the preliminary conclusions, Bruce said that the current tap water consumption reflects past consumption is an assumption, not a finding. Geary commented that Jessica should anticipate the question, is it safe for me to get a blood transfusion? This prompted Greg to ask whether nursing mothers transfer their PFCs to their offspring, and Geary said yes, we know that they do. But it’s only a slight transfer—not much. Pat asked, what message should we recommend in answer to the question about blood donation? Geary said the reduction in PFCs in blood donation is just a few ng/ml, but that the finding is important for the people who give blood. Alan said that blood donation is of tremendous social value, so we need to be very careful in giving that message. Geary recommended talking with David Mair, the medical director at the Red Cross, and to use their message, rather than giving an MDH message. Bruce asked for a clarification on the conclusion that people whose PFC levels did not decline from 2008 to 2010 were more likely to have had lower levels in 2008 and did not donate blood. What does “lower” mean? You need to think about magnitude and come up with some sort of explanation—analytical variance or individual variation. Carin Huset, from the Public Health Laboratory, replied, saying that, for people who had low levels in 2008, even though the PFC levels rose a little in 2010, the changes were statistically insignificant, given lab variability. We’re talking about people who were at low levels before and were a little higher in 2010, but still well below the rest of the population. Jessica added, we think that particular population is basically at background levels. In short, Greg suggested, if you had low PFC levels in 2008 and did not donate blood, your results in 2010 will be about the same. Alan asked, Geary, do you expect this population to continue to have their levels decline? There has to be a bottom somewhere. Geary answered, what you’ll see is that the levels will get to a point where the half‐life gets muddy. This, he argued, is why it’s a good idea to repeat the PFC study in these participants now, before the PFC levels get down to the background levels in the population. Geary added, given the data, what does this mean in terms of health risk limits and drinking water standards? Rita Messing answered that the relative source contribution for drinking water is currently 0.2 (20% of a person’s daily PFC consumption compared to other sources of exposure), and the Environmental Health division has no plans to change it, because we don’t have any information that would lead us to raise it. 82 Biomonitoring Updates These reported on the current status of the 
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Pregnancy and Newborns Exposure Study Fond du Lac Community Biomonitoring Study As time was short, panel members moved on to the next item on the agenda. Minnesota National Children’s Study Newborn Mercury Project Proposal In light of the limited time, Jessica quickly reviewed a few slides for this proposal. The impetus, she said, was the response to findings that 10% of the newborns tested in MDH’s Mercury in Newborns in the Lake Superior Basin13 study had blood mercury levels that might harm cognitive development. The EHTB Advisory Panel had recommended looking at mercury in newborns in other regions of Minnesota. The goal of this recommendation is to learn whether babies in other areas of the state are being exposed to potentially harmful mercury levels during prenatal development. This project proposes that MDH’s EHTB Program would obtain matched cord blood, cord blood spot, maternal blood, and newborn blood spot samples that were collected from participants in the former National Children’s Study (NCS ) South Dakota State University (SDSU) Vanguard pilot study. It covers Brookings, SD, and three counties in western Minnesota. The MDH Public Health Laboratory would analyze all of the samples for total mercury content and analyze cord blood for lead, cadmium, and several forms of mercury. The project would address two Advisory Panel recommendations: 1. Because the lab method used in the Mercury in Newborns study is novel, do mercury levels in newborn blood spots accurately reflect those in more common measures of prenatal exposure to mercury, including cord blood, the basis for the EPA reference dose? 2. Is the observation that 10% of newborns tested had been exposed to potentially harmful levels of mercury unique to babies in the Lake Superior, or are these exposures also occurring in other parts of Minnesota? The aims of the project are to… 1. Measure and compare total mercury levels in specimens of maternal blood, cord blood, and newborn blood spots from mother‐baby pairs to see if these different measures of prenatal exposure to mercury give comparable results. 2. Measure and compare paired whole cord blood and cord blood spot mercury levels to learn whether levels measured in the blood spot accurately reflect those in the 13
Mercury in Newborns in the Lake Superior Basin, conducted by MDH’s Fish Consumption Advisory Program and funded by the Environmental Protection Agency (EPA), with additional support from MDH’s Environmental Health Tracking and Biomonitoring (EHTB) Program. 83 blood sample, to verify that the process of spotting the blood onto filter paper and extracting the sample does not introduce error into the measurement. This would validate the use of blood spots as a surrogate for whole blood. 3. Explore the extent of newborn exposure to mercury in Minnesota outside of the Lake Superior Basin to learn whether and where newborns in other regions of the state also have elevated mercury levels at birth. In addition, because the MDH Pregnancy and Newborns Exposure Study is also measuring lead and cadmium in cord blood, the SDSU NCS samples can serve as a comparison population from a very different area of Minnesota. She cautioned that the Vanguard cord blood collection method may have compromised the quality of the cord blood samples. If so, MDH may decide not to submit this proposal. Given that time was limited, panel members posed no questions, and the meeting moved on to new business. New business Bruce asked for panel members’ ideas or thoughts for new business. Geary asked whether the biomonitoring summit idea was still in the planning. Jean answered that, yes, it is in our plan, but it has been pushed farther out on the calendar. Aggie noted that a number of bills had been introduced in the legislature that would ban certain products or contaminants, such as triclosan, used in antibacterial soaps, or BPA (Bisphenol A), used in some plastics. Others have proposed an expansion of the Toxic Free Kids Act. Motion to adjourn Bruce requested a motion to adjourn. Pat McGovern offered the motion, Jill Heins‐
Nesvold seconded the motion, and the meeting adjourned. 84 EnvironmentalHealthTracking&BiomonitoringAdvisoryPanelRoster
As of June 2013 Bruce Alexander, PhD University of Minnesota School of Public Health Environmental Health Sciences Division MMC 807 Mayo 420 Delaware Street SE Minneapolis, Minnesota 55455 612‐625‐7934 [email protected] At‐large representative Fred Anderson, MPH Washington County Department of Public Health and Environment 14949 62nd St N Stillwater MN 55082 651‐430‐6655 [email protected] At‐large representative Alan Bender, DVM, PhD Minnesota Department of Health Health Promotion and Chronic Disease Division 85 East 7th Place PO Box 64882 Saint Paul, MN 55164‐0882 651‐201‐5882 [email protected] MDH appointee David DeGroote, PhD St. Cloud State University 740 4th Street South St. Cloud, MN 56301 320‐308‐2192 [email protected] Minnesota House of Representatives appointee Melanie Ferris Wilder Foundation 451 Lexington Parkway N St. Paul, MN 55104 651‐280‐2660 [email protected] Nongovernmental organization representative Thomas Hawkinson, MS, CIH, CSP Toro Company 8111 Lyndale Avenue S Bloomington, MN 55420 [email protected] 952‐887‐8080 Statewide business org representative Jill Heins Nesvold, MS American Lung Association of Minnesota 490 Concordia Avenue St. Paul, Minnesota 55103 651‐223‐9578 [email protected] Nongovernmental organization representative 85 Patricia McGovern, PhD, MPH University of Minnesota School of Public Health Environmental Health Sciences Division MMC Mayo 807 420 Delaware St SE Minneapolis MN 55455 612‐625‐7429 [email protected] University of Minnesota representative Geary Olsen, DVM, PhD 3M Medical Department Corporate Occupational Medicine MS 220‐6W‐08 St. Paul, Minnesota 55144‐1000 651‐737‐8569 [email protected] Statewide business organization representative Gregory Pratt, PhD Minnesota Pollution Control Agency Environmental Analysis and Outcomes Division 520 Lafayette Road St. Paul, MN 55155‐4194 651‐757‐2655 [email protected] MPCA appointee Cathy Villas‐Horns, MS, PG Minnesota Department of Agriculture Pesticide and Fertilizer Management Division 625 Robert Street North St. Paul, Minnesota 55155‐2538 651‐201‐6291 cathy.villas‐[email protected] MDA appointee Lisa Yost, MPH, DABT ENVIRON International Corporation 333 West Wacker Drive, Suite 2700 Chicago, IL 60606 Local office 886 Osceola Avenue St. Paul, Minnesota 55105 Phone: 651‐225‐1592 Cell: 651‐470‐9284 [email protected] At‐large representative Vacant Minnesota Senate appointee 86 Biographicalsketchesofadvisorypanelmembers
Bruce H. Alexander is a Professor in the Division of Environmental Health Sciences at the University of Minnesota’s School of Public Health. Dr. Alexander is an environmental and occupational epidemiologist with expertise in cancer, reproductive health, respiratory disease, injury, exposure assessment, and use of biological markers in public health applications. Fred Anderson is an epidemiologist at the Washington County Department of Public Health and Environment and has over 30 years of public health experience. .He holds a Master of Public Health (MPH) in environmental and infectious disease epidemiology from the University of Minnesota and is a registered environmental health specialist. For over 20 years, he has led county‐wide disease surveillance and intervention programs, including numerous multidisciplinary epidemiologic investigations. Alan Bender is the Section Chief of Chronic Disease and Environmental Epidemiology at the Minnesota Department of Health. He holds a Doctor of Veterinary Medicine degree from the University of Minnesota and a PhD in Epidemiology from Ohio State University. His work has focused on developing statewide surveillance systems, including cancer and occupational health, and exploring the links between occupational and environmental exposures and chronic disease and mortality. David DeGroote is Dean of the College of Science and Engineering and Professor of Biological Sciences at St. Cloud State University. He has been at St. Cloud State University since 1985, initially as an Assistant Professor in Biological Sciences. He served as Department Chair from 1996 to 2003 before moving to the Dean’s Office. Most recently he had focused on providing up‐to‐date academic programming and facilities that serve the needs of Minnesota employers in the health sciences, engineering, computing, biosciences, and STEM education. Melanie Ferris is a Research Scientist at Wilder Research, a nonprofit research organization based in St. Paul, Minnesota. She conducts a variety of program evaluation and applied research projects focused primarily on public health and mental health. She has worked on a number of recent projects that focus on identifying disparities across populations and using existing data sources to develop meaningful indicators of health and wellness. Examples of these projects include a study of health inequities in the Twin Cities region related to income, race, and place, development of a dashboard of mental health and wellness indicators for youth living in Hennepin County, and work on local community health needs assessments. She has a Master’s of Public Health degree in Community Health Education from the University of Minnesota’s School of Public Health. 87 Tom Hawkinson is the Corporate Environmental, Health, and Safety Manager for the Toro Company in Bloomington, MN. He completed his MS in Public Health at the University of Minnesota, with a specialization in industrial hygiene. He is certified in the comprehensive practice of industrial hygiene and a certified safety professional. He has worked in EHS management at a number of Twin Cities based companies, conducting industrial hygiene investigations of workplace contaminants and done environmental investigations of subsurface contamination both in the United States and Europe. He has taught statistics and mathematics at both graduate and undergraduate levels as an adjunct, and is on the faculty at the Midwest Center for Occupational Health and Safety A NIOSH‐Sponsored Education and Research Center School of Public Health, University of Minnesota. Jill Heins Nesvold serves as the Director of the Respiratory Health Division for the American Lung Association in Iowa, Minnesota, North Dakota, and South Dakota. Her responsibilities include program oversight and evaluation related to asthma, chronic obstructive lung disease (COPD), lung cancer, and influenza. Jill holds a master’s degree in health management and a short‐course master’s of business administration. Jill has published extensively in a variety of public health areas. Pat McGovern is a Professor in the Division of Environmental Health Sciences at the University of Minnesota’s School of Public Health. Dr. McGovern is a health services researcher and nurse with expertise in environmental and occupational health policy and health outcomes research. She serves as the Principal Investigator for the National Children’s Study (NCS) Center serving Ramsey County, one of 105 study locations nationwide. The NCS is the largest, long‐term study of children’s health and development in the US and the assessment of environmental exposures will include data collection from surveys, biological specimens and environmental samples. Geary Olsen is a corporate scientist in the Medical Department of the 3M Company. He obtained a Doctor of Veterinary Medicine (DVM) degree from the University of Illinois and a Master of Public Health (MPH) in veterinary public health and PhD in epidemiology from the University of Minnesota. For 27 years he has been engaged in a variety of occupational and environmental epidemiology research studies while employed at Dow Chemical and, since 1995, at 3M. His primary research activities at 3M have involved the epidemiology, biomonitoring (occupational and general population), and pharmacokinetics of perfluorochemicals. 88 Greg Pratt is a research scientist at the Minnesota Pollution Control Agency. He holds a Ph.D. from the University of Minnesota in Plant Physiology where he worked on the effects of air pollution on vegetation. Since 1984 he has worked for the MPCA on a wide variety of issues including acid deposition, stratospheric ozone depletion, climate change, atmospheric fate and dispersion of air pollution, monitoring and occurrence of air pollution, statewide modeling of air pollution risks, and personal exposure to air pollution. He is presently cooperating with the Minnesota Department of Health on a research project on the Development of Environmental Health Outcome Indicators: Air Quality Improvements and Community Health Impacts. Cathy Villas Horns is the Hydrologist Supervisor of the Incident Response Unit (IRU) within the Pesticide and Fertilizer Management Unit of the Minnesota Department of Agriculture. Cathy holds a Master of Science in Geology from the University of Delaware and a Bachelor of Science in Geology from Carleton College and is a licensed Professional Geologist in MN. The IRU oversees or conducts the investigation and cleanup of point source releases of agricultural chemicals (fertilizers and pesticides including herbicides, insecticides, fungicides, etc. as well as wood treatment chemicals) through several different programs. Cathy has worked on complex sites with Minnesota Department of Health and MPCA staff, and continues to work with interagency committees on contaminant issues. She previously worked as a senior hydrogeologist within the IRU, and as a hydrogeologist at the Minnesota Pollution Control Agency and an environmental consulting firm. Lisa Yost is a Principal Consultant at ENVIRON, an international consulting firm. She is in their Health Sciences Group, and is based in Saint Paul, Minnesota. Ms. Yost completed her training at the University of Michigan’s School of Public Health and is a board‐certified toxicologist with expertise in evaluating human health risks associated with substances in soil, water, and the food chain. She has conducted or supervised risk assessments under CERCLA, RCRA, or state‐led regulatory contexts involving a wide range of chemicals and exposure situations. Her areas of specialization include exposure and risk assessment, risk communication, and the toxicology of such chemicals as PCDDs and PCDFs, PCBs, pentachlorophenol (PCP), trichloroethylene (TCE), mercury, and arsenic. Ms. Yost is a recognized expert in risk assessment and has collaborated in original research on exposure issues, including background dietary intake of inorganic arsenic. She is currently assisting in a number of projects, including a complex multi‐pathway risk assessment for PDDD/Fs that will integrate extensive biomonitoring data collected by the University of Michigan. Ms. Yost is also an Adjunct Instructor at the University of Minnesota’s School of Public Health. 89 This page intentionally left blank. 90 StaffBiosketches
Wendy Brunner, PhD, serves as surveillance epidemiologist for the MDH Asthma Program since 2002, and joined the MN EPHT program on a part‐time basis in fall 2009. Previously, she worked on occupational respiratory disease studies for MDH. She has a master’s degree in Science and Technology Studies from Rensselaer Polytechnic Institute and a master’s degree in Environmental and Occupational Health from the University of Minnesota (UMN). She is currently a doctoral student in the Division of Epidemiology and Community Health at the University of Minnesota. Tess Gallagher, MPH, graduated from the University of Michigan’s School of Public Health with a master’s in Occupational Environmental Epidemiology. She completed her thesis on the effects of heat on hospitalizations in Michigan. She currently is a CSTE/CDC Epidemiology Fellow in EPHT working on birth defects, pesticides, climate change, and a follow‐up study of the Northeast Minneapolis Community Vermiculite Investigation cohort. Jean Johnson, PhD, MS, is Program Director/Principal Investigator for Minnesota’s Environmental Public Health Tracking and Biomonitoring Program. Dr. Johnson received her Ph.D. and M.S. degrees from the University of Minnesota’s School of Public Health in Environmental Health. She has 25 years of experience working with the state of Minnesota in the environmental health field. As an environmental epidemiologist at MDH, her work has focused on special investigations of population exposure and health, including studies of chronic diseases related to air pollution and asbestos exposure, and exposure to drinking water contaminants. She is currently the Principal Investigator on an EPA grant to develop methods for measuring the public health impacts of population exposure to particulate matter (PM) in air. She is also an adjunct faculty member at the UMN School of Public Health. Mary Jeanne Levitt, MBC, is the communications coordinator with the Minnesota Environmental Public Health Tracking program. She has a Master’s in Business Communications and has worked for over 20 years in the public and non‐profit sector in project management of research and training grants, communications and marketing strategies, focus groups and evaluations of educational needs of public health professionals. She serves on 3 institutional review boards which specialize in academic research, oncology research, and overall clinical research. Paula Lindgren, MS, received her Master’s of Science in Biostatistics from the University of Minnesota. She works for MDH as a biostatistician and provides statistical and technical support to the MN EPHT and Biomonitoring programs for data reports, publications, web‐based portal dissemination and presentations in the Chronic Disease and Environmental Epidemiology section. Ms. Lindgren has also received training in the area of GIS for chronic disease mapping and analysis. In addition to her work for MN EPHT, she works for various programs within Chronic Disease and Environmental 91 Epidemiology including the Asthma program, Center for Occupational Health and Safety, Minnesota Cancer Surveillance System, and Cancer Control section. Matthew Montesano, BA, is the Data Access Portal Coordinator for the MN EPHT Program. He designs, develops, and maintains content for the Public Health Data Access portal, trains portal users around the state, and evaluates portal use and impact. Before joining MDH in March 2013, he gained extensive experience communicating science to a lay audience and developing web‐based public health communications material as a consultant in the nonprofit sector. Matthew received an undergraduate degree in Science in Society from Wesleyan University in Middletown, CT, and is in the final stages of completing a Master's in Public Health degree in Community Health Promotion at the UMN School of Public Health. Barbara Scott Murdock, MA, MPH, is a Program Planner for the EHTB program, responsible for leading strategic planning and communications with stakeholders and the EHTB Advisory Panel. A biologist and public health professional, she has over 30 years of experience in writing and editing professional publications. Recently a grants coordinator/writer for social science faculty at the UMN, she also served as biomonitoring project manager at MDH (2001‐2003); senior research fellow in the Center for Environment & Health Policy, UMN School of Public Health (1995‐2001); director of water and health programs at the Freshwater Foundation (1991‐1992); and founding editor of the Health & Environment Digest, a peer‐reviewed publication for environmental health and management professionals in the US and Canada (1986‐1992). She holds a SB in biochemistry from the University of Chicago, an MA in zoology from Duke University, and an MPH from the University of Minnesota. Jessica Nelson, PhD, is an epidemiologist with the Minnesota Environmental Public Health Tracking and Biomonitoring Program, working primarily on design, coordination, and analysis of biomonitoring projects. Jessica received her PhD and MPH in Environmental Health from the Boston University School of Public Health where her research involved the epidemiologic analysis of biomonitoring data on perfluorochemicals. Jessica was the coordinator of the Boston Consensus Conference on Biomonitoring, a project that gathered input and recommendations on the practice and uses of biomonitoring from a group of Boston‐area lay people. Jeannette M. Sample, MPH, is an epidemiologist with the MN EPHT program at MDH, working on the collection and statistical analysis of public health surveillance data for EPHT. She also works on research collaborations with academic partners relating to reproductive outcomes and birth defects. Before joining EPHT, she was a CSTE/CDC Applied Epidemiology Fellow with MDH’s Birth Defect Information System. She received her Master’s in epidemiology and biostatistics from The George Washington University in Washington, DC. 92 Blair Sevcik, MPH, is an epidemiologist with the Minnesota Environmental Public Health Tracking (EPHT) program at the Minnesota Department of Health, where she works on the collection and statistical analysis of public health surveillance data for EPHT. Prior to joining EPHT in January 2009, she was a student worker with the MDH Asthma Program. She holds a Master’s of Public Health in epidemiology from the UMN School of Public Health. Chuck Stroebel, MSPH, is the MN EPHT Program Manager. He provides day‐to‐day direction for program activities, including: 1) development and implementation of the state network, 2) development and transport of NCDMs and metadata for the national network, and 3) collaboration and communication with key EPHT partners and stakeholders. Chuck received a Master’s of Public Health in Environmental Health Sciences from the University of North Carolina (Chapel Hill). He has over 15 years of expertise in environmental health, including areas of air quality, pesticides, climate change, risk assessment, and toxicology. Chuck also played a key role in early initiatives to build tracking capacity at the Minnesota Department of Health. Currently, he is a member of the IBIS Steering Committee (state network), the MDH ASTHO Grant Steering Committee (climate change), and the Northland Society of Toxicology. He also serves on the MN EPHT Technical and Communications Teams. Allan N. Williams, MPH, PhD, is an environmental and occupational epidemiologist in the Chronic Disease and Environmental Epidemiology Section at the Minnesota Department of Health. He is the supervisor for the MDH Center for Occupational Health and Safety, which currently includes both the state‐funded and federally‐funded Environmental Public Health Tracking and Biomonitoring programs. For over 25 years, he has worked on issues relating to environmental and occupational cancer, cancer clusters, work‐related respiratory diseases, and the surveillance and prevention of work‐related injuries among adolescents. He has served as the PI on two NIOSH R01 grants, as a co‐investigator on four other federally‐funded studies in environmental or occupational health, and is an adjunct faculty member in the University of Minnesota’s School of Public Health. He received an MA in Biology from Indiana University, an MPH in Environmental Health and Epidemiology from the University of Minnesota, and a PhD in Environmental and Occupational Health from the University of Minnesota 93 EnvironmentalHealthTrackingandBiomonitoringStatute
$1,000,000 each year is for environmental health tracking and biomonitoring. Of this amount, $900,000 each year is for transfer to the Minnesota Department of Health. The base appropriation for this program for fiscal year 2010 and later is $500,000. 144.995 DEFINITIONS; ENVIRONMENTAL HEALTH TRACKING AND BIOMONITORING. (a) For purposes of sections 144.995 to 144.998, the terms in this section have the meanings given. (b) "Advisory panel" means the Environmental Health Tracking and Biomonitoring Advisory Panel established under section 144.998. (c) "Biomonitoring" means the process by which chemicals and their metabolites are identified and measured within a biospecimen. (d) "Biospecimen" means a sample of human fluid, serum, or tissue that is reasonably available as a medium to measure the presence and concentration of chemicals or their metabolites in a human body. (e) "Commissioner" means the commissioner of the Department of Health. (f) "Community" means geographically or nongeographically based populations that may participate in the biomonitoring program. A "nongeographical community" includes, but is not limited to, populations that may share a common chemical exposure through similar occupations, populations experiencing a common health outcome that may be linked to chemical exposures, populations that may experience similar chemical exposures because of comparable consumption, lifestyle, product use, and subpopulations that share ethnicity, age, or gender. (g) "Department" means the Department of Health. (h) "Designated chemicals" means those chemicals that are known to, or strongly suspected of, adversely impacting human health or development, based upon scientific, peer‐
reviewed animal, human, or in vitro studies, and baseline human exposure data, and consists of chemical families or metabolites that are included in the federal Centers for Disease Control and Prevention studies that are known collectively as the National Reports on Human Exposure to Environmental Chemicals Program and any substances specified by the commissioner after receiving recommendations under section 144.998, subdivision 3, clause (6). (i) "Environmental hazard" means a chemical or other substance for which scientific, peer‐
reviewed studies of humans, animals, or cells have demonstrated that the chemical is known or reasonably anticipated to adversely impact human health. (j) "Environmental health tracking" means collection, integration, analysis, and dissemination of data on human exposures to chemicals in the environment and on diseases potentially caused or aggravated by those chemicals. 144.996 ENVIRONMENTAL HEALTH TRACKING; BIOMONITORING. Subdivision 1. Environmental health tracking. In cooperation with the commissioner of the Pollution Control Agency, the commissioner shall establish an environmental health tracking program to: (1) coordinate data collection with the Pollution Control Agency, Department of Agriculture, University of Minnesota, and any other relevant state agency and work to promote the sharing of and access to health and environmental databases to develop an environmental health tracking system for Minnesota, consistent with applicable data practices laws; (2) facilitate the dissemination of aggregate public health tracking data to the public and researchers in accessible format; (3) develop a strategic plan that includes a mission statement, the identification of core priorities for research and epidemiologic surveillance, and the identification of internal and external stakeholders, and a work plan describing future program development and addressing issues having to do with compatibility with the Centers for Disease Control and Prevention's National Environmental Public Health Tracking Program; (4) develop written data sharing agreements as needed with the Pollution Control Agency, Department of Agriculture, and other relevant 94 state agencies and organizations, and develop additional procedures as needed to protect individual privacy; (5) organize, analyze, and interpret available data, in order to: (i) characterize statewide and localized trends and geographic patterns of population‐based measures of chronic diseases including, but not limited to, cancer, respiratory diseases, reproductive problems, birth defects, neurologic diseases, and developmental disorders; (ii) characterize statewide and localized trends and geographic patterns in the occurrence of environmental hazards and exposures; (iii) assess the feasibility of integrating disease rate data with indicators of exposure to the selected environmental hazards such as biomonitoring data, and other health and environmental data; (iv) incorporate newly collected and existing health tracking and biomonitoring data into efforts to identify communities with elevated rates of chronic disease, higher likelihood of exposure to environmental hazards, or both; (v) analyze occurrence of environmental hazards, exposures, and diseases with relation to socioeconomic status, race, and ethnicity; (vi) develop and implement targeted plans to conduct more intensive health tracking and biomonitoring among communities; and (vii) work with the Pollution Control Agency, the Department of Agriculture, and other relevant state agency personnel and organizations to develop, implement, and evaluate preventive measures to reduce elevated rates of diseases and exposures identified through activities performed under sections 144.995 to 144.998; and (6) submit a biennial report to the chairs and ranking members of the committees with jurisdiction over environment and health by January 15, beginning January 15, 2009, on the status of environmental health tracking activities and related research programs, with recommendations for a comprehensive environmental public health tracking program. Subd. 2. Biomonitoring. The commissioner shall: (1) conduct biomonitoring of communities on a voluntary basis by collecting and analyzing biospecimens, as appropriate, to assess environmental exposures to designated chemicals; (2) conduct biomonitoring of pregnant women and minors on a voluntary basis, when scientifically appropriate; (3) communicate findings to the public, and plan ensuing stages of biomonitoring and disease tracking work to further develop and refine the integrated analysis; (4) share analytical results with the advisory panel and work with the panel to interpret results, communicate findings to the public, and plan ensuing stages of biomonitoring work; and (5) submit a biennial report to the chairs and ranking members of the committees with jurisdiction over environment and health by January 15, beginning January 15, 2009, on the status of the biomonitoring program and any recommendations for improvement. Subd. 3. Health data. Data collected under the biomonitoring program are health data under section 13.3805. 144.997 BIOMONITORING PILOT PROGRAM. Subdivision 1. Pilot program. With advice from the advisory panel, and after the program guidelines in subdivision 4 are developed, the commissioner shall implement a biomonitoring pilot program. The program shall collect one biospecimen from each of the voluntary participants. The biospecimen selected must be the biospecimen that most accurately represents body concentration of the chemical of interest. Each biospecimen from the voluntary participants must be analyzed for one type or class of related chemicals. The commissioner shall determine the chemical or class of chemicals to which community members were most likely exposed. The program shall collect and assess biospecimens in accordance with the following: (1) 30 voluntary participants from each of three communities that the commissioner identifies as likely to have been exposed to a designated chemical; (2) 100 voluntary participants from each of two communities: (i) that the commissioner identifies as likely to have been exposed to arsenic; and (ii) that the commissioner identifies as likely to have been exposed to mercury; and (3) 100 voluntary participants from each of two communities that the commissioner identifies as likely to have been exposed to perfluorinated chemicals, including 95 perfluorobutanoic acid. Subd. 2. Base program. (a) By January 15, 2008, the commissioner shall submit a report on the results of the biomonitoring pilot program to the chairs and ranking members of the committees with jurisdiction over health and environment. (b) Following the conclusion of the pilot program, the commissioner shall: (1) work with the advisory panel to assess the usefulness of continuing biomonitoring among members of communities assessed during the pilot program and to identify other communities and other designated chemicals to be assessed via biomonitoring; (2) work with the advisory panel to assess the pilot program, including but not limited to the validity and accuracy of the analytical measurements and adequacy of the guidelines and protocols; (3) communicate the results of the pilot program to the public; and (4) after consideration of the findings and recommendations in clauses (1) and (2), and within the appropriations available, develop and implement a base program. Subd. 3. Participation. (a) Participation in the biomonitoring program by providing biospecimens is voluntary and requires written, informed consent. Minors may participate in the program if a written consent is signed by the minor's parent or legal guardian. The written consent must include the information required to be provided under this subdivision to all voluntary participants. (b) All participants shall be evaluated for the presence of the designated chemical of interest as a component of the biomonitoring process. Participants shall be provided with information and fact sheets about the program's activities and its findings. Individual participants shall, if requested, receive their complete results. Any results provided to participants shall be subject to the Department of Health Institutional Review Board protocols and guidelines. When either physiological or chemical data obtained from a participant indicate a significant known health risk, program staff experienced in communicating biomonitoring results shall consult with the individual and recommend follow‐up steps, as appropriate. Program administrators shall receive training in administering the program in an ethical, culturally sensitive, participatory, and community‐based manner. Subd. 4. Program guidelines. (a) The commissioner, in consultation with the advisory panel, shall develop: (1) protocols or program guidelines that address the science and practice of biomonitoring to be utilized and procedures for changing those protocols to incorporate new and more accurate or efficient technologies as they become available. The commissioner and the advisory panel shall be guided by protocols and guidelines developed by the Centers for Disease Control and Prevention and the National Biomonitoring Program; (2) guidelines for ensuring the privacy of information; informed consent; follow‐up counseling and support; and communicating findings to participants, communities, and the general public. The informed consent used for the program must meet the informed consent protocols developed by the National Institutes of Health; (3) educational and outreach materials that are culturally appropriate for dissemination to program participants and communities. Priority shall be given to the development of materials specifically designed to ensure that parents are informed about all of the benefits of breastfeeding so that the program does not result in an unjustified fear of toxins in breast milk, which might inadvertently lead parents to avoid breastfeeding. The materials shall communicate relevant scientific findings; data on the accumulation of pollutants to community health; and the required responses by local, state, and other governmental entities in regulating toxicant exposures; (4) a training program that is culturally sensitive specifically for health care providers, health educators, and other program administrators; (5) a designation process for state and private laboratories that are qualified to analyze biospecimens and report the findings; and (6) a method for informing affected communities and local governments representing those communities concerning biomonitoring activities and for receiving comments from citizens concerning those activities. (b) The commissioner may enter into contractual agreements with health clinics, 96 community‐based organizations, or experts in a particular field to perform any of the activities described under this section. 144.998 ENVIRONMENTAL HEALTH TRACKING AND BIOMONITORING ADVISORY PANEL. Subdivision 1. Creation. The commissioner shall establish the Environmental Health Tracking and Biomonitoring Advisory Panel. The commissioner shall appoint, from the panel's membership, a chair. The panel shall meet as often as it deems necessary but, at a minimum, on a quarterly basis. Members of the panel shall serve without compensation but shall be reimbursed for travel and other necessary expenses incurred through performance of their duties. Members appointed by the commissioner are appointed for a three‐year term and may be reappointed. Legislative appointees serve at the pleasure of the appointing authority. Subd. 2. Members. (a) The commissioner shall appoint eight members, none of whom may be lobbyists registered under chapter 10A, who have backgrounds or training in designing, implementing, and interpreting health tracking and biomonitoring studies or in related fields of science, including epidemiology, biostatistics, environmental health, laboratory sciences, occupational health, industrial hygiene, toxicology, and public health, including: (1) at least two scientists representative of each of the following: (i) nongovernmental organizations with a focus on environmental health, environmental justice, children's health, or on specific chronic diseases; and (ii) statewide business organizations; and (2) at least one scientist who is a representative of the University of Minnesota. (b) Two citizen panel members meeting the scientific qualifications in paragraph (a) shall be appointed, one by the speaker of the house and one by the senate majority leader. (c) In addition, one representative each shall be appointed by the commissioners of the Pollution Control Agency and the Department of Agriculture, and by the commissioner of health to represent the department's Health Promotion and Chronic Disease Division. Subd. 3. Duties. The advisory panel shall make recommendations to the commissioner and the legislature on: (1) priorities for health tracking; (2) priorities for biomonitoring that are based on sound science and practice, and that will advance the state of public health in Minnesota; (3) specific chronic diseases to study under the environmental health tracking system; (4) specific environmental hazard exposures to study under the environmental health tracking system, with the agreement of at least nine of the advisory panel members; (5) specific communities and geographic areas on which to focus environmental health tracking and biomonitoring efforts; (6) specific chemicals to study under the biomonitoring program, with the agreement of at least nine of the advisory panel members; in making these recommendations, the panel may consider the following criteria: (i) the degree of potential exposure to the public or specific subgroups, including, but not limited to, occupational; (ii) the likelihood of a chemical being a carcinogen or toxicant based on peer‐reviewed health data, the chemical structure, or the toxicology of chemically related compounds; (iii) the limits of laboratory detection for the chemical, including the ability to detect the chemical at low enough levels that could be expected in the general population; (iv) exposure or potential exposure to the public or specific subgroups; (v) the known or suspected health effects resulting from the same level of exposure based on peer‐reviewed scientific studies; (vi) the need to assess the efficacy of public health actions to reduce exposure to a chemical; (vii) the availability of a biomonitoring analytical method with adequate accuracy, precision, sensitivity, specificity, and speed; (viii) the availability of adequate biospecimen samples; or (ix) other criteria that the panel may agree to; and (7) other aspects of the design, implementation, and evaluation of the environmental health tracking and biomonitoring system, including, but not limited to: (i) identifying possible community partners and sources of additional public or private funding; (ii) developing outreach and educational methods and materials; and 97 (iii) disseminating environmental health tracking and biomonitoring findings to the public. Subd. 4. Liability. No member of the panel shall be held civilly or criminally liable for an act or omission by that person if the act or omission was in good faith and within the scope of the member's responsibilities under sections 144.995 to 144.998. INFORMATION SHARING. On or before August 1, 2007, the commissioner of health, the Pollution Control Agency, and the University of Minnesota are requested to jointly develop and sign a memorandum of understanding declaring their intent to share new and existing environmental hazard, exposure, and health outcome data, within applicable data privacy laws, and to cooperate and communicate effectively to ensure sufficient clarity and understanding of the data by divisions and offices within both departments. The signed memorandum of understanding shall be reported to the chairs and ranking members of the senate and house of representatives committees having jurisdiction over judiciary, environment, and health and human services. Effective date: July 1, 2007 This document contains Minnesota Statutes, sections 144.995 to 144.998, as these sections were adopted in Minnesota Session Laws 2007, chapter 57, article 1, sections 143 to 146. The appropriation related to these statutes is in chapter 57, article 1, section 3, subdivision 4. The paragraph about information sharing is in chapter 57, article 1, section 169. The following is a link to chapter 57: http://ros.leg.mn/bin/getpub.php?type=law&ye
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