Environmental Health Tracking and Biomonitoring Program
Advisory Panel Meeting Agenda
for February 11, 2014: 1:00 – 4:00 pm
at The American Lung Association in Minnesota
490 Concordia Avenue, St. Paul, Minnesota
Time
Agenda Items
Presenters
Description/expected outcome
1:00
Welcome &
Introductions
Patricia
McGovern,
Chair
Panel members & audience are invited to
introduce themselves
1:05
Tracking Updates
Jean Johnson
Chuck Stroebel
Information item: Jean will give a brief
review of MN Tracking program updates.
Panel members are invited to ask questions
or comment on updates.
Chuck Stroebel
Discussion Item: MDH will present an
overview of the agency’s health equity
initiative. Chuck will highlight data on the
portal that reveals health disparities and
sub-county level data.



Governor’s award
New portal content
CDC projects update
1:10
Advancing Health Equity
and Portal Data
Demonstration
1:30
Discussion
Questions for the panel:


1:50
1
New Pesticide Poisoning
Data Demonstration
Tess Konen
Over the next 3-5 yrs, how could data
on the portal be enhanced to inform
actions that advance health equity?
Over the next 3-5 yrs, what could the
biomonitoring program be doing to
inform actions that advance health
equity and environmental justice?
Information item: Tess will give a brief
preview of new Tracking pesticide
poisoning data. Panel members are invited
to ask questions or provide comment.
Time
Agenda Items
Presenters
Description/expected outcome
2:05
Refreshments
2:15
East Metro PFC3
Biomonitoring Project
Update
Christina
Rosebush
Information item: Christy will present the
status of the PFC3 project. Panel members
are invited to ask questions or comment.
2:25
Biomonitoring Updates
Paul Moyer,
Public Health
Laboratory
Jessica Nelson
Information item: Jessica and Paul will
briefly describe recent status of metals
projects and laboratory. Panel members
are invited to ask questions or comment.
2:40
Newborns’
Biomonitoring Protocol:
Community Selection
Jessica Nelson
Discussion Item: Jessica will review the
draft protocol and rationale for the
community selection and consent process
that is proposed.
3:00
Discussion
Questions to the panel:




3:30
Sustaining Minnesota
Biomonitoring:
Workgroup Progress
Report
Kristin Van
Amber
Does the panel agree with the
proposed clinic-based community
selected for this project?
How might we might best engage the
community, and recruit participants?
Should enrollment be open to all
women seen for prenatal care in the
community clinics, or should eligibility
be further limited by race/ethnicity?
Given that urine is a better biomarker
for inorganic mercury found in skinlightening creams, should we also
collect a maternal urine sample?
Discussion item: Kristin will report on the
first 2 meetings of the Sustaining
Minnesota Biomonitoring Workgroup, draft
charter and work plan.
2
Time
Agenda Items
3:40
Discussion
Presenters
Description/expected outcome
Questions to the panel:


3:50
New Business
3:55
Audience Questions
4:00
Motion to adjourn
Does the charter and plan fit with your
understanding of the group’s charge?
What suggestions do you have to assist
them in developing an action plan for
sustaining Minnesota Biomonitoring?
Note to audience: The panel asks that audience members hold comments and questions on discussion
items until the end of the meeting, when the chair will invite questions from the audience. Audience
members are asked to identify themselves when they speak, and to please record their names and
affiliations on the list at the sign-in table. Meetings are recorded on audiotape.
3
Table of Contents
Section Overview: Advancing Health Equity and Portal Data Demonstration ............................................ 8
Section Overview: New Pesticide Poisoning Data Demonstration............................................................ 14
Section Overview: East Metro PFC3 Biomonitoring Project Update ........................................................ 18
Section Overview: Biomonitoring Updates ................................................................................................ 21
Section Overview: Newborns’ Biomonitoring Protocol ............................................................................. 24
Section Overview: Sustaining Minnesota Biomonitoring: Workgroup Progress Report ........................... 31
Section Overview: Other Information........................................................................................................ 36
4
Section Overview: Environmental Public Health Tracking Updates
Jean will give a brief review of MN Environmental Public Health Tracking program updates and respond
to questions.
This section includes status reports on the following projects:



MN Tracking portal team receives Governor’s award
New portal content
CDC projects update
Information Item:
After this presentation, panel members are invited to comment and ask questions.
5
Tracking Updates
MN Tracking Portal Team Receives Governor's Award
In December 2013, the Minnesota Tracking Program’s data portal team received a Governor's Award for
Continuous Improvement, which recognizes outstanding achievement in reforming state government
and saving taxpayers' dollars. Honored at a reception at the State Capitol, this team from the Minnesota
Department of Health (MDH) was one of just six throughout Minnesota's state government agencies to
receive this award. At the reception, Governor Mark Dayton acknowledged the "tremendous efforts to
improve the quality of services provided to Minnesotans."
The award recognizes work that increases productivity and enhances the efficiency of state government
services. The portal team is honored that their work to make public health data available and accessible
to Minnesotans is helping to fulfill Governor Dayton’s mission of "Better Government for a Better
Minnesota." By relying on best practices in usability, plain language, and web design, the portal
provides public health information that is user-friendly and widely accessible, and that uses costeffective strategies to communicate health information that is actionable.
MDH has developed estimates of costs avoidance and savings provided through the MN Tracking
Program’s data access portal, as well as improvements in government services.



Cost avoidance in handling data requests: $3.6 million/year
Improved timeliness in access to data: 24/7 on the portal web site
Cost savings in IT architecture: scalable to integrate broad public health data sets
Currently the portal has data on 18 topics with approximately 2000 unique visitors per month. Chuck
Stroebel, Minnesota’s Tracking Program Manager, estimates that costs avoided are substantial given the
staff time and handoffs associated with handling individual data requests, one-by-one.
Furthermore, with the IT infrastructure and standards for data now in place for tracking, MDH can
efficiently integrate new data into the MN Tracking data portal. Several MDH programs have
approached the MN Tracking Program to explore requirements to integrate data into the portal. Agency
and IT programs are viewing the portal as a win-win to avoid duplication and rework required for
maintaining multiple, independent on-line systems. For more, see the Governor’s blog: Governor
Dayton Recognizes State Employees for Reforming State Government.
New Portal Content
New Private Well Data Launched
In January 2014 the MN Tracking Program added new data for private wells (arsenic) to the data access
portal, including interactive maps and charts. These data were developed in collaboration with the MDH
Well Management Section, and through MDH participation in two CDC National Tracking Network
project teams charged to develop and evaluate data on private wells. MDH currently is working to
promote the availability of these new maps through conferences, newsletters, and other media
channels. Minnesota is one of a handful of grantees in the CDC National Tracking Network who were
able to successfully develop and launch data on private wells. Portal data are limited arsenic; however,
6
data on additional contaminants may be considered in the future if additional resources become
available. View Arsenic in Private Wells: Facts & Figures
Updated Air Quality Data Launched
In December, the MN Tracking Program launched updated air quality data for fine particles and ozone.
These data were developed by the Minnesota Pollution Control Agency, in collaboration with the MN
Tracking Program. These data include monitored and modeled values, using the US EPA Downscaler
model. In the spring of 2014, the MN Tracking Program and MPCA will initiate development of a new Air
Quality Index indicator. View the updated air quality data
CDC National Tracking Network – Update and Renewal Opportunity
The MN Tracking Program continues to participate in four national CDC Tracking Project Teams that are
working to demonstrate use of state/national tracking data. The next Advisory Panel meeting will
include additional information about Minnesota’s involvement and products of these teams, and their
work is expected to conclude in March-April 2014.
MDH’s current award (Year 5) from the CDC National Tracking Network concludes in July 2014, and we
will be applying for competitive renewal for our cooperative agreement in spring 2014. Panel members
are encouraged to contact Jean Johnson or Chuck Stroebel for questions or to share ideas for our
renewal application.
7
Section Overview: Advancing Health Equity and Portal Data
Demonstration
MDH will present a brief overview of the agency’s broad health equity initiative. Chuck will highlight
data on the portal that reveals health disparities and opportunities for presenting sub-county level data.
Questions for the panel:


Over the next 3-5 years, how could data on the portal be enhanced to inform actions that
advance health equity?
Over the next 3-5 years, what could the biomonitoring program be doing to inform actions that
advance health equity and environmental justice?
8
Advancing Health Equity
Background
Minnesota is one of the healthiest states in the country. However, a statewide assessment has found
that not all Minnesotans have the same chances to be healthy. Those with less money, and populations
of color and American Indians, consistently have less opportunity for health and experience worse
health outcomes.
The Minnesota Legislature in 2013 directed the Minnesota Department of Health (MDH) and its partners
to complete a report about advancing health equity (AHE) in Minnesota. The report assesses
Minnesota’s health disparities and recommends best practices, policies, processes, data strategies, and
other steps that will promote health equity for all Minnesotans.
The project officially launched October 22, 2013. The report was due to the Legislature February 1,
2014.
A summary of key principals from the report is provided below. A copy of the complete final report can
be found on the MDH website here: Advancing Health Equity
Advancing Health Equity in Minnesota: Report to the Legislature
Recommendations for Advancing Health Equity Principles guiding the recommendations
An initial analysis of the nearly 200 pages of inquiry responses and an overview of research related to
health equity have yielded six key principles that helped to guide the development of a set of
recommendations for advancing health equity in Minnesota. The ideas encompassed in the principles
are directed toward MDH as well as toward local government and community partners, other state
agencies, health plans and health care providers, and organizations in many sectors across Minnesota.
Please note that neither these principles nor the recommendations are presented in any intentional
priority order.
Principal 1. The importance of examining all policies for structural inequities and health equity.
The inquiry responses indicated that health equity could not be advanced without a deliberate and
concerted effort toward developing public policies that support health and address the structural
inequities, including structural racism, evident in many arenas. Examples included were land use,
transportation planning, education, health care, and the environment. Suggestions included establishing
criteria and routinely conducting health equity impact assessments for policy, systems, and
environmental decisions, when deemed appropriate.
Emphasis was also placed on the need to make an analysis of structural racism and other structural
inequities key elements of health policy and health equity discussions.
Principle 2: The value of pulling people together and collaborating to advance health equity.
In the inquiry responses, frequent references were made to the importance of bringing a variety of
sectors and actors to the discussion table to expand understanding among decision makers and get
9
health equity to a central place in policy development. Particular emphasis was given to the role of the
commissioner of MDH in convening cabinet-level discussions and decisions to advance health equity.
Principle 3: The need for strong community relationships and shared decision-making to make a real
difference.
Inquiry respondents frequently noted that MDH and local public health leaders re primarily
white/European, and that most MDH advisory councils also are primarily composed of white
practitioners. Concern was expressed that there are unrealistic expectations for the few persons of color
present on these councils to speak for entire racial/ethnic communities, and that communities of color
and American Indians often have been used as a means to an end (e.g., to gather research data), rather
than as entities with their own ideas and solutions. Respondents recommended that, in addition to
addressing disparities in the workforce, MDH must take the time needed and develop stronger
relationships with the American Indian, African American, Hispanic/Latino, Asian-Pacific Islander, and
other racial/ethnic/cultural communities, including new immigrants and refugees. Additional responses
were to provide payment as a means of facilitating participation of community members, as not
everyone is paid by their employers to attend meetings.
Many noted that new initiatives fail to seek community input at the very beginning, and/or do not
assure adequate representation of the communities that will be most affected by the initiative or
program on task forces and work groups, thus the solutions, policy development, or decisions are not as
effective as they should be. Building relationships in the community is the first step toward sharing
power in decision making.
Principle 4: That health equity must become an integral aspect of all efforts, not just a focused effort
in one area.
Comments made in the inquiry responses noted that if health equity is to be advanced, it has to become
the responsibility of all parts of the department (similar to the idea of interagency or cross-sector work).
Historically, however, some people both inside and outside of MDH have assumed that eliminating
health disparities and advancing health equity are the sole responsibility of the Office of Minority and
Multicultural Health (OMMH). This narrow view of health equity needs to be overcome by explicit
efforts to institutionalize the concept and activities throughout MDH.
The many workforce issues identified in the inquiry include both workforce development and the
cultural competence of MDH staff. The inquiry responses frequently identified a lack of racial/ethnic
diversity among MDH leadership and professional staff. This lack of diversity in these positions reflects
many different issues, including structural racism in educational and degree-development processes,
financial and cultural barriers to post-high school education, and state hiring processes (including webbased applications, resume development, job requirements that give priority to degrees over
experience, and more). MDH faces many difficulties in recruiting, developing, promoting and retaining
employees that represent the populations served by MDH and the state. In addition to workforce
development, a numberof comments emphasized the daily stress faced by some employees in the
workplace environment at MDH, in part due to the lack of racial and ethnic diversity and cultural
sensitivity noted above. And while many in MDH recognize the importance and need to look at their
work through both a structural racism and a health equity lens, not all agree.
10
Some inquiry responses noted that a number of health occupations (especially some para-professional
fields, e.g., dieticians) are white (and often female) dominated areas, thus the values and expectations
these professionals bring to their work reflect the white middle class, affecting the working environment
of the profession, the standards they develop, and the ways in which each profession interacts with
communities that have a different culture and different values. It also affects who is attracted to these
professions, learns about them or has the opportunity to see them at work, or views these professions
as valuable and relevant to their communities’ needs.
Principle 5: The need to acknowledge and support the capacity of Minnesota communities to create
health.
Frequent reference was made in the inquiry responses to the need for MDH to understand and respond
to the differing capacities of community organizations who seek any competitive grants from the
department. A number of structural issues, such as financial requirements for grantees, result in
advantages being giving to larger, established and well-resourced organizations rather than emerging
organizations from the communities most affected by health disparities. Throughout the inquiry
responses, comments were made about the importance of early and meaningful engagement of
stakeholders in decisions that affect them.
Principle 6: The need to improve the collection, analysis, and use of data for health equity.
Responses in the inquiry to questions about data for health equity included:
That data should be disaggregated into more racial, ethnic and linguistic groups to more accurately
reveal what is happening (e.g., broad categories of race do not advance understanding of the significant
differences among ethnic subgroups).
That more data and greater expertise in analysis are needed on sexual orientation and gender identity
(including statewide demographic data as well as provider data).
That the community needs to receive training and be involved in every phase, including planning and
the actual processes of data collection and analysis.
That data need to be analyzed from community (i.e., not just MDH professional) perspectives, and that
all those who will be analyzing the data need cultural competence.
A specific concern was expressed regarding the need for the involvement of investigators from the
community to be included in the interpretation and analysis of data collected from and about their
community. A number of responses also commented on the great value of qualitative data and
collecting stories from the community to help understand the quantitative data.
Links to other reports on this topic:
Wilder Foundation of MN: The unequal distribution of health in the Twin Cities
This report by the Blue Cross and Blue Shield of Minnesota Foundation and Wilder Research finds that
health and life expectancy are strongly connected to median area income, neighborhood conditions,
education and race.
11
CDC Chronic Disease Prevention and Health Promotion: Health Equity
This website provides links to various reports and resources on health disparities, social determinants of
health and heath equities from a national perspective.
Report to the Minnesota Legislature: Collection of Racial and Ethnic Health Data by the Minnesota
Departments of Health and Human Services (2011)
This report finds that only 60% of MDH datasets that include data on individuals include data on race,
ethnicity or language.
How can Tracking and Biomonitoring Inform MDH’s work: Advancing Health
Equity?
Biomonitoring Shows Disparities in Chemical Exposures
Data collected nationally and in other states show some striking disparities by race/ethnicity and
socioeconomic factors in exposure to chemicals, such as mercury and lead. Figure 1 shows that,
nationally, exposure to mercury is highest in women of child-bearing age who identified themselves as
"other race" (which includes Asian, Native American, Pacific Islander, and Caribbean). Nearly 16% of
women in the “other race” group had mercury in blood above a level of health concern, compared to
under 5% for non-Hispanic white women. Mercury is a potent neurotoxin that is especially harmful to a
developing fetus.
Figure 1: Percent of U.S. women aged 16-49 with mercury above a level of health concern (>5.8 g/L of
blood), by race/ethnicity
Source: National Health and Nutrition Examination Survey 1999-2004. For more information on
mercury levels in the U.S. population, see Mercury: Facts and Figures [link to:
https://apps.health.state.mn.us/mndata/biomonitoring_mercury] at MN Public Health Data Access.
In Minnesota, we do not know whether certain populations, such as African Americans or Asians, bear
an unequal burden of exposure to toxic metals and other chemicals, though there is good reason to
12
think that these disparities exist. The Minnesota Biomonitoring Program at MDH is working to fill this
gap by providing data that will inform decisions and evaluate actions for protecting the next generation.
For more information about Minnesota’s strategic plan for biomonitoring to address health disparities,
see MDH’s Framework for an Ongoing Biomonitoring Program
Environmental Public Health Tracking Data Portal Informs Actions to Eliminate Disparities
Access to public health data helps MN communities, agencies, and others to identify priorities, and to
evaluate the effectiveness of actions to eliminate health disparities. MDH is working to improve access
to data that are actionable and highlight areas where we can work together to advance health equity.
In 2011, for example, the MDH Tracking Program launched a new data portal that provides public access
to interactive charts, maps, and queries on the department’s web site. Data are available on over 18
health and environment topics, including poverty and income, health insurance (coverage), asthma,
cancer, lead poisoning, and chronic obstructive pulmonary disease (COPD). Data on this portal may be
used to evaluate trends for health disparities by race/ethnicity, age, gender, income and other factors.
For example, COPD, which includes emphysema and chronic bronchitis, is the fifth leading cause of
death in Minnesota. An estimated 4.1% (164,000) of Minnesotans report ever being diagnosed with
COPD (BRFSS, 2011). Figure 2 shows some striking disparities for COPD in Minnesota by race with high
rates of death for American Indians compared to people who are white, black or Asian.
Figure 2: Chronic Obstructive Pulmonary Disease (COPD) Mortality in MN by Race
Source: Minnesota Center for Health Statistics (2001-2010).
By using these and other data to inform public health actions for COPD in Minnesota, MDH and our
partners, such as the American Lung Association of MN, are able to identify areas to eliminate health
disparities, and to evaluate the effectiveness of initiatives to protect health.
For more information about COPD and other data topics available on the portal, visit Minnesota Public
Health Data Access
13
Section Overview: New Pesticide Poisoning Data Demonstration
MN Tracking staff will give a brief preview of new Tracking pesticide poisoning data and measures.
Information Item:
After this presentation, panel members are invited to comment and ask questions.
14
New Pesticide Poisoning Data Demonstration
The MN Tracking Program has developed new indicators to better understand and track the nature of
unintentional, non-occupational pesticide poisonings in Minnesota. These indiicators are: pesticide
poisoning emergency department (ED) visits, pesticide poisoning hospitalizations, and pesticide
exposure calls to the MN Poison Control Center. These indicators will be added as a new topic area on
the data access portal this spring.
The hospitalization and ED visits indicators were created using the Minnesota Hospitalization Discharge
Data (MNHDD), for the years 2000-2011. Rates of pesticide poisoning hospitalizations and ED visits were
calculated, and differences by sex, age, seasonal variation, and geographic location were assessed (see
sample charts). We found that males are more likely to be hospitalized for pesticide poisoning than
females in almost every age group. While males, aged 15-34 are more likely to be hospitalized, children
under four years of age have a much higher rate of ED visits than other age groups. There is a seasonal
pattern to pesticide poisoning ED visits, with increased visits in the summer and fall probably due to the
increased use of pesticides for pest management.
The indicator for pesticide poisoning calls was created using pesticide exposure calls from the MN
Poison Control Center for the years 2005-2012. The number of poison control center calls was calculated
for possible unintentional, non-occupational pesticide exposures by month, pesticide type, gender, and
age group. A seasonal pattern was detected in the number of pesticide calls, with more calls occurring
during the summer months. For pesticide exposure calls there are two vulnerable groups, children under
four and adults aged 20-64 years.
Symptoms of pesticide poisoning often mimic symptoms of colds or the flu. Therefore, pesticide
poisonings are often misdiagnosed and under-reported. Immediate symptoms may not be severe
enough to urge an individual to seek medical attention, or a doctor might not think to ask about
pesticide exposure. This may result in uncounted hospitalizations or ED visits and an underestimation of
pesticide poisonings. Some limitations of these data are the underestimation of rates for counties in
which residents are likely to cross state lines for healthcare, multiple hospital or emergency department
admissions by the same patient cannot be identified, and only those who sought care for their pesticide
poisoning symptoms are represented.
The main limitation to poison control center calls are that they are a voluntary reporting of data verified
only by follow-up phone calls by poison center specialists. These calls represent suspected exposures
from pesticides and serve as a proxy for the actual burden of pesticide poisonings. An actual poisoning
event can only be verified through medical outcome. Additionally, data acquired by telephone are
limited to those who have access to telephones and knowledge of the poison center service. An
unknown number of pesticide exposure events may occur for which no call was made.
Previously, data on pesticide poisonings in Minnesota were difficult to access. The data can be used to
inform prevention guidelines and for targeting public awareness & prevention campaigns during peak
times of accidental poisoning. With the access to Minnesota-specific data, MDH, the MN Department of
Agriculture, and others may use these data to inform poisoning prevention programs and initiatives.
15
The following are examples of charts developed for the data access portal. For questions, or more
information on charts that will be placed on the data access portal, contact Tess Konen—
epidemiologist—at [email protected].
0.8
Age-adjusted Rates per 100,000
0.7
Pesticide poisoning hospitalizations in Minnesota by
age and sex
0.6
0.5
0.4
0.3
Males
0.2
Females
0.1
0
0-4 years*
5-14 years*
15-34 years
35-64 years
65+ years
Age Categories
Source: Minnesota Hospital Association, 2002-2011.
*Unstable rates due to some counts less than 20.
16
Pesticide poisoning ED visits in Minnesota by age and sex
Age-specific ED Rate per 100,000
8
7
6
5
4
3
2
1
0
0-4 years
5-14 years
15-34 years
35-64 years
65+ years
Age
Males females
Source:Minnesota Hospital Association, 2007-2011.
Pesticide poisoning calls in Minnesota by month
Total Number of Pesticide Calls
2500
2000
1500
1000
COUNT
500
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Source: MN Poison Control Center, 2005-2012.
17
Section Overview: East Metro PFC3 Biomonitoring Project Update
This section provides a summary of current progress of the East Metro PFC3 Biomonitoring Project and
includes the following:





Project overview
IRB approval
Outreach to communities
Participant recruitment
o Original Cohort
o New Residents
Timeline
Information Item:

After this presentation, panel members are invited to comment and ask questions.
18
East Metro PFC3 Biomonitoring Project Update
Christy Rosebush, MPH
Project overview
The East Metro PFC3 Biomonitoring Project will measure blood levels of PFCs in residents of the East
Metro to check that measures put in place to reduce PFC exposures through drinking water are working.
We will measure PFCs in participants of the 2008 and 2010 PFC biomonitoring projects to verify that PFC
levels have continued to decline in this group. Additionally, we will measure PFCs in Oakdale residents
who moved to the city after the installation of a filtration system on the city water supply and compare
PFC levels to those seen in the U.S. general population. All participants will be asked to donate a blood
sample and complete a questionnaire about factors that may be related to their PFC levels.
IRB approval
The project received initial approval from the MDH and HealthEast IRBs in November 2013. Study
protocols and documents were amended based on MDH and HealthEast IRB stipulations and
suggestions, and on revised thinking about the project timeline. Amended protocols and documents
were resubmitted in December and subsequently approved by both IRBs.
Outreach to communities
Project staff have been working to inform local public health departments and legislators about the
project. Meetings have been conducted with officials from Washington County, Oakdale, and Cottage
Grove. Lake Elmo was informed of the project by phone. Outreach to legislators has also been initiated.
Media efforts to inform East Metro communities about the project will begin approximately February
12th, one week before recruitment materials are mailed.
Participant recruitment


Original Cohort: The 183 participants from the 2008 and 2010 projects who agreed to future
contact will be mailed a letter inviting their participation in the project, consent forms, and a
questionnaire around February 19th. Phone calls will be made to those who do not return the
materials to ensure they have received the mailing and understand the project.
New Residents: At least 500 Oakdale households that began municipal water service after
October 2006 will be sent an introductory letter, factsheet, and household survey to identify
eligible adults around February 19th. After recipients have had sufficient time to respond, a list
of eligible adults will be compiled. We will stratify this list into 2-3 groups based on length of
residence before randomly selecting a total of 200 individuals. These individuals will be mailed a
second letter inviting their participation in the project, consent forms, and a questionnaire.
Phone calls will be made to those who do not return the materials to ensure they have received
the mailing and understand the project. Replacement individuals will be randomly selected for
those who decline to participate.
Timeline
The first mailing to the original cohort and new residents is scheduled for February 19th. Beginning the
week of February 24th, we expect to begin receiving full study materials (letter, consent forms,
19
questionnaire) from the original cohort and household surveys from new residents. It may take up to
one month to collect household survey data and select potential new resident participants. The mailing
with full study materials is expected to go out to new residents in mid-March.
Once participants return their materials, they will receive a phone call from study staff thanking them,
clarifying questionnaire responses, and providing instructions for making their blood draw appointment
at the HealthEast Oakdale clinic. Clinic information will also be sent in the mail. Participants will likely
begin scheduling their appointments with the clinic in early March. Study staff will collect blood samples
from HealthEast Oakdale on a weekly basis and deliver them to the MDH PHL. Blood collection is
tentatively scheduled for March through June, though flexibility has been built into HealthEast Oakdale’s
contract due to the large number of participants.
Update on East Metro Cancer Report
MN Tracking and the Minnesota Cancer Surveillance System (MCSS) will soon release a report that
details cancer rates among residents of Dakota and Washington Counties between 2000 and 2009. This
report is an update to a 2007 report released by MCSS. It will provide Standardized Incidence Ratios for
select types of cancer and for all cancers combined down to the zip code level for 8 communities where
PFCs have raised health concerns. The data analysis phase is complete, and the full report will soon
enter the MDH review process. We anticipate that it will be released in winter 2014.
20
Section Overview: Biomonitoring Updates
This section contains status reports on the following projects:




Public Health Lab Recovering from Water Damage
Pregnancy and Newborns Exposure Study
NCS Newborn Mercury Biomarker Validation Supplemental Methodological Study
Riverside Newborn Mercury Project
Information Item:
After this presentation, panel members are invited to comment and ask questions.
21
Biomonitoring Updates
Public Health Lab Recovering from Water Damage
The Minnesota Department of Health (MDH) Public Health Laboratory suspended some of its laboratory
operations in January after the heating system failed on January 6, leading some building systems to
freeze and causing significant water leaks on several floors of the building. Crews from MDH and the
Minnesota Department of Administration’s Plant Management worked hard to protect equipment,
samples and supplies, and to remove equipment from affected areas. Crews stopped the leaks and are
now engaged in repair and recovery of the affected work and office areas.
Laboratory Director Joanne Bartkus has reported that several major pieces of equipment sustained
significant damage, including the instruments used to test metals, and the cost of the total damage
could exceed $1 million. MDH lab officials will decide how quickly they will be able to resume
operations. If necessary, Minnesota can call on neighboring states to help with some laboratory
testing. Damage to the metals laboratory and time needed for recovery will impact current and future
biomonitoring projects
Pregnancy and Newborns Exposure Study
Staff presented results on the relationship between mercury levels in paired newborn bloodspot and
cord blood samples at the October 2013 Advisory Panel meeting. Since the meeting, we submitted a
manuscript as a “Report from the Field” to Environmental Research; unfortunately, the paper was not
accepted for publication. The issues cited by the editor for the rejection include the large number of
non-detect values, which they felt questioned “the utility of this method for studying effects at low
exposures as well as the strength of your comparisons of the two biomarkers.” They also raised two
laboratory method issues: the fact that analyses were not done on split samples from the same blood
sample, and questions about how we expressed the concentration of mercury in a dried bloodspot
sample without truly knowing the volume of blood involved.
We are currently assessing whether to resubmit this manuscript to another journal. The MDH Public
Health Laboratory still plans to investigate whether the higher mercury levels found in cord compared to
spot blood could be related to the lab method. Cord blood samples with mercury levels >1 g/L will also
be analyzed for speciated mercury. Once these analyses are complete, we will summarize the results
and post them on the web site. The timeline for this project will likely be impacted by damage to the
metals laboratory caused by the water leakage described above.
NCS Newborn Mercury Biomarker Validation Supplemental Methodological Study
The status of this project has not changed since the October 2013 Advisory Panel meeting but will likely
be delayed due to damage in the metals laboratory. The project will measure mercury and other metals
in matched cord blood, newborn bloodspot, and maternal blood samples from National Children’s Study
participants enrolled by South Dakota State University’s Original Vanguard Center serving Brookings SD,
and Yellow Medicine, Pipestone, and Lincoln Counties, MN. All samples (83 pairs of matched newborn
bloodspot and cord blood samples, with maternal blood samples at birth from 49 of these mothers)
have been received by the MDH Public Health Laboratory. Samples will be analyzed for total mercury
and cord blood will also be analyzed for speciated mercury, lead, and cadmium. Staff are still finalizing
Data Use Agreements with the NCS.
22
Riverside Newborn Mercury Project
The status of this project has not changed since the October 2013 Advisory Panel meeting. The MDH
Public Health Laboratory has received 160 newborn bloodspot samples collected from participants in
the Riverside Birth Study. Lab analysis for total mercury was expected to begin this fall but may be
further delayed due to damage sustained in the metals laboratory.
23
Section Overview: Newborns’ Biomonitoring Protocol
Staff will review the project rationale and draft protocol, and will give an overview of the community
selection and consent processes that are proposed. Panel members are invited to ask questions or
provide comment on any aspect of the proposal.
The proposed project will use a clinic-based approach to recruit women during their 2nd or 3rd trimester
of pregnancy and obtain consent at that time for MDH to test their baby’s newborn screening blood
spot for total mercury. In addition, for a subset of the study population, we propose to obtain a cord
blood sample for further analyses including mercury speciation, additional metals (lead and cadmium),
and comparison to the blood spot results.
Staff are currently in the planning stages of the project and have begun to identify and meet with
specific clinics that serve the communities of interest for this project. We have met with a number of
colleagues at MDH and other organizations such as St. Paul-Ramsey County Public Health and the MN
Council of Health Plans to determine possible clinics and how best to approach them.
Questions to the panel:



Does the panel agree with the proposed staff recommendations for community selection, based
on prior recommendations that MDH target communities of greatest concern?
Does the panel have advice for how we might best engage the community, and recruit
participants?
Does it make sense to narrow our focus to just the specific ethnic populations of concern, or
should enrollment be open to all women served by the selected clinics?
Exposure to inorganic mercury through skin-lightening creams has emerged as a key concern. Given that
urine is a better biomarker for inorganic mercury, should we also collect a maternal urine sample?
24
Newborns’ Biomonitoring Protocol
Jessica Nelson, PhD
Draft Partial Protocol: Minnesota Family Environmental Exposure Tracking (MN FEET)
Minnesota Biomonitoring: Chemicals in People
Introduction
Fetal exposure to mercury is of great public health concern because even small amounts of mercury can
damage the developing infant’s brain and nervous system (NRC, 2000). Mercury exposure may affect
future learning abilities, memory, and attention, and lead to learning and behavioral problems later in
life (NRC, 2000). In utero and early life exposure to other metals, such as lead, can also have
neurodevelopmental effects.
The Minnesota Department of Health’s Mercury in Newborns in the Lake Superior Basin pilot study
measured mercury in newborns born in the Lake Superior region of the state by testing a leftover
portion of the dried newborn bloodspot routinely collected from infants at birth. The study found that
10% of Minnesota babies tested had mercury exposure above a level of health concern (MDH, 2011).
This pilot study raised important public health questions, including whether other groups of
Minnesotans, beyond those in the Lake Superior region, have elevated mercury exposures.
Studies of newborns in other parts of the country have found marked disparities by race/ethnicity in
exposure to mercury; certain groups, such as some Asian populations and African Americans, have been
shown to have higher exposures than white newborns (King et al., 2013; Lederman et al., 2008). Beyond
the Lake Superior mercury results, information on newborn mercury exposures in Minnesota is limited
to one small MDH study of newborns born to primarily white, affluent, urban mothers. The sample size
(n=48) limited conclusions we can draw from the study, but only 2% of participants had exposures above
a level of health concern. No other information on Minnesota newborn mercury exposures is available,
and we do not know whether disparities in exposure exist in our state population.
The EHTB Advisory Panel recommended that Minnesota Biomonitoring conduct additional mercury
biomonitoring to find out whether newborns in regions outside of the Lake Superior Basin are also
exposed to harmful levels of mercury during prenatal development and to identify the sources of those
exposures where possible. The Panel further recommended that MDH continue biomonitoring of
newborn bloodspots and, again where possible, expand our evaluation of the bloodspot method as a
way of measuring newborn exposure to mercury. This work is part of a larger effort, based on our
strategic plan, to track exposures to chemicals in vulnerable Minnesota populations with a focus on
pregnant women, children, and disadvantaged communities. Results will inform decisions and evaluate
actions for protecting future generations.
25
Rationale and goals
To address these questions, Minnesota Biomonitoring proposes to measure mercury (and other metals,
if possible) in bloodspots from approximately 6001 newborns in Minnesota. We also hope to measure
mercury and other metals in a smaller number of paired cord blood samples.
Because we do not have the resources to do a state-wide sample, we will focus instead on targeted
populations that may be at risk for higher mercury exposures. Populations of interest in Minnesota
include urban newborns from certain racial/ethnic backgrounds, including Somali, Hmong, and African
American newborns. In a future phase of the project, we are also interested in testing newborns from a
non-Metro area of the state.
Minnesota is home to the largest Somali population in the U.S., with an estimated 50,000 Somali people
living in the state (A. Adawe, personal communication, January 24, 2014). A particularly high
concentration of Somali people live in the Minneapolis-St. Paul Metro area. Concern about mercury
exposure in this population has grown in recent years as information has emerged about the use of skinlightening creams by Somali women (Adawe and Oberg, 2013). Though cosmetic products containing
mercury are illegal in Minnesota, they are still widely available for purchase. The St. Paul-Ramsey County
Public Health Department, MDH, and the Minnesota Pollution Control Agency tested skin-lightening
creams purchased locally and found that 11 out of 27 products contained mercury, some at levels up to
33,000 ppm (Adawe and Oberg, 2013). Interviews with Somali women found that they commonly apply
the products to their entire body, sometimes multiple times a day, including when they are pregnant
and breastfeeding. No data are available on mercury exposures in Minnesota Somali women or
newborns. Biomonitoring studies in different parts of the U.S. have found elevated urinary mercury
levels in women who used skin-lightening creams, including Dominican women in New York City and
Hispanic women in Arizona, California, New Mexico, and Texas (McKelvey et al., 2011; Weldon et al.,
2000).2
A large Hmong population has also settled in Minnesota; over 66,000 Hmong people now live in the
state, with the greatest concentration (over 29,000 people) living in St. Paul (Hmong American
Partnership). Mercury exposures are a concern in this population for multiple reasons. Anecdotally, the
use of skin-lightening creams may be prevalent in Hmong women, and folk remedies and medicines
used by Hmong people may contain metals (CDC, 1984). Mercury exposure through fish consumption is
1
The final number of bloodspots tested will depend on the budget and the other specimen types
collected.
2
Urine is the preferred biomarker for measuring exposure to inorganic mercury, the form most
commonly found in skin-lightening creams. Inorganic mercury is present in blood, but has a short halflife (4 or 5 days), compared to 45 days in urine (Sin et al., 2003). Speciating blood mercury helps better
understand inorganic mercury exposure, but blood levels of inorganic mercury reflect very recent
exposure only.
26
also a concern as local fishing is common in this community and some may rely on subsistence fishing. A
study in Green Bay, WI found that 60% of Hmong households fished (Hutchison and Kraft, 1994), though
a biomonitoring study in the same community did not find particularly elevated mercury levels (Schantz
S.L. et al., 2010). Other biomonitoring studies have consistently found Asian populations to have higher
mercury levels than other groups. In New York City, babies born to China-born Asian women had
geometric mean cord blood mercury concentrations of 12.6 µg/L compared to 4.4 µg/L for the rest of
the population (Lederman et al., 2008). No biomonitoring data are available on mercury exposures in
Hmong or other Asian populations in Minnesota.
Another group that may be at higher risk for mercury exposure is African Americans. In Rhode Island,
infants born to African American mothers had geometric mean cord blood mercury concentrations of
2.1 µg/L, compared to 0.5 µg/L for the population as a whole (King et al., 2013). This study did not look
at exposure sources so it is not entirely clear why this elevation occurred; it could be related to diet or
use of personal care products that contain mercury. Again, no biomonitoring data exists on mercury
exposures in Minnesota African Americans.
MN FEET proposes to measure mercury in the residual portion of newborn bloodspots collected for the
MDH Newborn Screening Program. Biomonitoring for metals using newborn bloodspots is a relatively
new approach and involves a novel laboratory method. A small MDH project determined that mercury
levels in newborn bloodspots were strongly correlated with levels in paired cord blood, a more standard
measure of fetal exposure to mercury, but that bloodspot measurements may underestimate mercury
exposure compared to cord blood measures. The EHTB Advisory Panel recommended that MDH
continue with mercury biomonitoring using bloodspots, but that we also investigate further the
methodological question of whether newborn bloodspots are a reliable measure of newborn exposure
to mercury. Thus, MN FEET also proposes to collect paired cord blood samples from a subset of
newborns and compare mercury levels in the two specimen types.
MN FEET will provide an evidence-base for targeting available resources and public health actions to
reduce mercury exposures. For newborns whose results indicate elevated exposures, we will partner
with St. Paul-Ramsey County Public Health, other local public health agencies, and our collaborating
health clinics to be sure that appropriate follow-up is available. In addition, materials for advising
women about safe fish consumption are available through MDH’s Fish Consumption Advisory Program.
MN FEET has the following goals:
1.
2.
3.
4.
Characterize mercury exposures in Minnesota newborns from certain targeted groups and
identify disparities that may exist.
Determine the proportion of babies with mercury exposures above a level of health concern
and initiate a public health response for these families.
Investigate sources of mercury exposure using survey data.
Establish an infrastructure for ongoing biomonitoring surveillance of newborn exposures in
Minnesota.
If resources permit, MN FEET will also address these goals:
27
1.
2.
Measure mercury in paired cord blood from a subset of newborns to continue investigation
of the relationship between mercury levels in spot v. cord blood.
Investigate sources of exposure using mercury speciation of cord blood samples.
3.
Characterize exposure to other metals (lead, cadmium) in cord blood.
Study Design
Study population and eligibility
The study population will comprise newborns born to pregnant women receiving prenatal care at 3-4
Metro-area clinics that focus on serving the populations of interest described above. We will enroll 200250 families from each clinic. Eligibility will be open to all women seen at that clinic for prenatal care
during their 2nd or 3rd trimester. Enrollment will place special emphasis on outreach and
communication with Asian, Somali, and African American women. Eligible women must be receiving
prenatal care at one of the participating clinics and plan to allow the collection of newborn bloodspots
for the MDH Newborn Screening Program.
Clinic collaborations
For this phase of the project, we hope to partner with three or four Metro-area clinics that serve the
above-mentioned populations. Possible clinics include:



East Side Clinic, part of West Side Community Health Center, serving a large Hmong population
HealthPartners Riverside, Midway, and/or Brooklyn Park Clinics or Smiley’s and Cook Clinic (both
University of Minnesota Physicians clinics), serving a large Somali population
Northpoint or Broadway Clinics, serving a large African American population
We may also explore other avenues of participant recruitment, including working with the WIC and
family home visiting programs.
Participant recruitment and informed consent
Many logistics still need to be determined with participating clinics, but the plan is that trained clinic
staff will introduce the project to patients during a 2nd or 3rd trimester visit, possibly when education
about the MDH Newborn Screening Program is initiated. Staff will give the families background on the
project and answer any questions. Fliers on the project will also be posted in clinic waiting and exam
rooms. Information will be available in different languages. An advantage of working through the clinics
is that they have interpreters and community health workers on staff who can assist with the project. If
the family feels they have enough information and do not have questions, clinic staff will ask for
consent. If they have questions, they can contact MDH and choose to participate in the study at a later
visit.
In tandem with clinic recruitment, we will do outreach to the communities of interest with the help of
local public health agencies and their community health workers. This will include meetings with
community leaders and the use of appropriate media to reach women in our target populations (radio,
TV, and web sites).
28
Informed consent will ask for permission to use a portion of the newborn bloodspot already being
collected for the MDH Newborn Screening Program for mercury testing. Participants will also be asked
to answer a short set of questions about possible mercury exposure sources. For a subset of participants
(most likely all women recruited at one clinic, 200-250 participants), the consent will also allow for the
collection of a cord blood sample at the time of the infant’s delivery. For all biospecimens collected, the
consent will ask whether or not the family wants to receive their individual results. Participants will be
informed that they will receive a small gift as compensation for their involvement.
[Sections of the protocol that still need to be completed]
Study methods
Exposure questionnaire
Obtaining bloodspot samples from the Newborn Screening Program
Cord blood sample collection, storage and transport
Laboratory analysis methods
Data management and analysis
Communication of biomonitoring results to participants
Data privacy
Limitations
Risks and benefits
--------------------------------------References
Adawe, A., Oberg, C., 2013. Skin-lightening practices and mercury exposure in the Somali community.
Minn Med. 96, 48-9.
CDC, 1984. Nonfatal Arsenic Poisoning in Three Hmong Patients -- Minnesota. MMWR. 33, 347-9.
Hutchison, R., Kraft, C. E., 1994. Hmong fishing activity and fish consumption. Journal of Great Lakes
Research. 20, 471-478.
King, E., et al., 2013. Mercury, lead, and cadmium in umbilical cord blood. J Environ Health. 75, 38-43.
Lederman, S. A., et al., 2008. Relation between cord blood mercury levels and early child development in
a World Trade Center cohort. Environ Health Perspect. 116, 1085-91.
29
McKelvey, W., et al., 2011. Population-based inorganic mercury biomonitoring and the identification of
skin care products as a source of exposure in New York City. Environ Health Perspect. 119, 203-9.
MDH, Mercury Levels in Blood from Newborns in the Lake Superior Basin. Vol. EPA GLNPO ID 2007-942,
2011.
NRC, Toxicological Effects of Methylmercury. National Academy Press, Washington, DC, 2000.
Hmong American Partnership, 2010 Census Hmong and Southeast Asian Americans Data.
Schantz S.L., et al., 2010. Contaminant profiles in Southeast Asian immigrants consuming fish from
polluted waters in northeastern Wisconsin. Environ Res. 110, 33-9.
Sin, K. W., Tsang, H. F., 2003. Large-scale mercury exposure due to a cream cosmetic: community-wide
case series. Hong Kong Med J. 9, 329-34.
Weldon, M. M., et al., 2000. Mercury poisoning associated with a Mexican beauty cream. West J Med.
173, 15-8; discussion 19.
30
Section Overview: Sustaining Minnesota Biomonitoring: Workgroup
Progress Report
Kristin Van Amber will report on the first two meetings of the Sustaining Minnesota Biomonitoring
Workgroup. The workgroup has developed a draft charter and work plan included here for your review
prior to discussion of the questions below. Panel members are invited to ask questions and comment on
these materials.
Questions to the Panel:


How does the charter and work plan as presented at the meeting fit with your understanding of
the workgroup’s charge?
What recommendations do you have to assist them in achieving their goal of developing an
action plan for sustaining Minnesota Biomonitoring?
31
Sustaining Minnesota Biomonitoring: Workgroup Progress Report
Sustaining Minnesota Biomonitoring Workgroup Charter
1.27.14
Workgroup Purpose
This group will explore potential funding sources for an ongoing biomonitoring program in Minnesota
and guide MDH in developing an action plan to ensure the long-term sustainability of the program.
An ongoing biomonitoring program will track exposures to chemicals in vulnerable Minnesota
populations with a focus on pregnant women, children, and disadvantaged communities. Led by an
expert Advisory Panel and strategic plan, the program will do systematic, repeated biomonitoring in
targeted Minnesota communities for chemicals that are a concern in the state because of our natural
environment, industries, and diverse people. Gathering this information will allow us to track trends
over time, identify groups that are highly exposed to chemicals, and, ultimately, inform decisions and
evaluate actions for protecting future generations.
Workgroup Scope
Help MDH staff develop a sustainable funding action plan, which identifies the steps we need to take to
put the program in the best position to secure longer-term funding.
What’s in: Identifying customers of our information, and future funding strategies,; working
with MDH to identify and prioritize action steps. Actions to be recommended may include
identifying grant funding sources, working with local foundations, and/or best methods for
informing or engaging state legislators and advocacy organizations.
What’s out: The scope will not include developing a communications or marketing plan. A
separate communications plan is being developed and implemented to supplement the work of
this group.
Workgroup Roles and Responsibilities:
Program Champion:
Workgroup Leader:
Facilitator: Kris Van Amber (Management Analysis Division)
Prepares meeting agenda, notes, and documents, facilitates discussion.
MDH program staff responsibilities:



Support Team Leader in meeting preparation and logistics
Attend meetings, provide timely information to the workgroup as requested.
Implement action plan steps and report back to the Task Force.
32
Workgroup members:
Alan Bender, MDH
David DeGroote, St. Cloud State University
Melanie Ferris, Wilder Foundation,
Jill Heins-Nesvold, American Lung Association
Lisa Yost, Environ International
Deb Hendricks, University of Minnesota
Mary Manning, MDH
Workgroup member responsibilities:
Participate in approximately 5-6 meetings to advise and recommend to staff a sustainable funding action
plan, review implementation and report to the full MN Tracking Advisory Panel.
Level of Agreement: Group consensus
Duration: One year, December 2013- Dec.2014. (may be extended per group decision)
33
DRAFT Work Plan for Sustaining Minnesota Biomonitoring Workgroup
Revised January 24, 2014
Activity
Goal
Who
When
1. Customer conversation
and SWOT analysis
Identify the customers and how
to engage them in this
conversation.
Workgroup
Jan 2014
Product: Targeted
(vulnerable populations &
chemical) data to inform
the protection of future
generations.
Assess the current state of
biomonitoring funding activities
by identifying the current
strengths, weaknesses,
opportunities and threats
2. Report to EHTB
Advisory Panel
Report on activities to date and
request input
Workgroup
Feb 2014
3. Cost
Estimate the annual operational
cost of an effective, sustained
biomonitoring program
MDH staff
March 2014
4. Funding strategies
Expand thinking about funding
and consider strategies that may
provide funding for years to
come.
MDH staff research
alternative funding
approaches and
provide information
for workgroup
April 2014
5. Prioritize alternative
funding strategies
Develop criteria and Identify best Workgroup
strategies to move forward.
May 2014
6. Report to EHTB
Advisory Panel
Report on activities to date and
request input
Workgroup
June 2014
7. Action Plan
Recommendation:
operationalize the
strategies
Identify and prioritize action
steps and resources that are
crucial to sustaining
biomonitoring in MN.
Workgroup
July 2014
34
8. Operationalize the Plan Begin to implement the action
plan as recommended and
report progress.
MDH staff
August 2014
Activity
Goal
Who
Whe n
Identify the customers a nd how to engage the m in this conversation.
Workgroup
Jan 2014
Feb 2014
9.
Customer conversation and SW OT analysis
Product: Targete d (vul nerable populations & chemi cal) data to infor m the pr otection of future ge nerations.
Assess the current state of biomonitoring funding activities by identi fying the current strengths, weakness es, opportunities and thr eats
10.
Report on activities to date and reque st input
Workgroup
Estimate the annual operational cost of a n effe ctive, sustaine d biomonitoring progra m
MDH staff
11.
Expand thinking about funding and consider strategies that may provide funding for years to come.
MDH staff re search alternative funding approaches and provide information for workgroup
12.
Develop criteria and I denti fy best strategies to move forward.
Workgroup
13.
Report on activities to date and reque st input
Workgroup
14.
Identify and prioritize acti on step s and re sour ces that are cr ucial to s ustaining bi omonitoring in M N.
Workgroup
Begin to imple ment the acti on plan a s recommen ded and rep ort progress.
MDH staff
15.
Operationali ze the Plan
August 2014
Work Product: An Action Plan for Sustaining Minnesota Biomonitoring at MDH.
Funding
approach
Strategies
Action steps
Who
When
Resources
needed
Strategies
Action steps
Who
Whe n
Resour ces needed
State funding
National funding
Foundation
funding
Other
Fundi ng approa ch
State funding
National fundi ng
Foundation fundi ng
Other
35
Section Overview: Other Information
This section contains documents that may be of interest to panel members.






2014 Upcoming Advisory Panel Meeting dates
October 8, 2013 Advisory Panel Meeting Summary
Advisory Panel Roster
Biographical Sketches of Advisory Panel Members
Biographical Sketches of Staff
Environmental Health Tracking and Biomonitoring Legislation
36
2014 Advisory Panel Meetings
Tuesday, June 10
1–4 pm
Tuesday, October 14
1-4 pm
All meetings for 2014 will take place at
The American Lung Association of Minnesota
490 Concordia Avenue
St. Paul, Minnesota
37
Environmental Health Tracking & Biomonitoring Program Summary:
October 8, 2013 Advisory Panel Meeting
Advisory Panel: Bruce Alexander, Alan Bender, David De Groote, Jill Heins Nesvold, Pat McGovern,
Geary Olsen, Cathy Villas-Horns, Lisa Yost
MDH staff: Betsy Edhlund, Tess Gallagher, Jean Johnson, Jim Kelly, Mary Jeanne Levitt, Aggie Leitheiser,
Mary Manning, Pat McCann, Matthew Montesano, Paul Moyer, Barbara Scott Murdock, Jessica Nelson,
Christina Rosebush, Chuck Stroebel, Paul Swedenborg, Janis Taramelli
MAD consultants: Barbara Deming, Kris Van Amber
Welcome and introductions
Patricia McGovern, chair, welcomed the attendees and invited the panel members and audience to
introduce themselves.
Agenda Overview
Jean Johnson briefly reviewed the topics and discussion items. Explaining that the first half of the
meeting would focus on mercury in newborns, she asked the panel to consider the material presented in
the first three presentations and then, given the program’s limited funding, to consider how best to
move forward with future mercury projects. She asked panel members to discuss and vote on the best
blood specimen (cord blood or newborn spots).
Pregnancy and Newborn Exposure Study: Data Analysis
Jessica Nelson reported on the cord blood to newborn bloodspot (NBS) comparison project carried out
in collaboration with Dr. Ruby Nguyen, principal investigator for the University of Minnesota’s arm of
The Infant Development and Exposure Study (TIDES). The project measured mercury in 48 paired
newborn bloodspot–cord blood samples and found detectable mercury in both cord and newborn
bloodspots in 16 paired samples. Among these 16 paired samples, mercury levels were slightly higher in
cord blood: the average cord-to-NBS ratio was 1.3 + 0.4, ranging from 0.5 to 2.1. Mercury levels in the
two sample types were moderately correlated using the Spearman test. Using information reported by
the mothers during their first trimester, mercury levels in cord blood were associated with seafood
meals per week.
This Advisory Panel presentation explored the finding that cord blood mercury levels were 30% higher
on average than NBS mercury levels. Given that cord blood is fetal blood and that NBS are collected
within two days of birth and should be very similar, Jessica said that the divergence required an
explanation. Did it arise from the differing analytical methods used to measure the two sample types in
the laboratory, or did it reflect a biological difference?
Jessica reviewed possible reasons why laboratory methods might explain the disparity: The laboratory
must use different analytical methods for the two sample types. One method is used to extract mercury
from whole cord blood. The other must extract mercury from small spots of blood dried on filter paper,
an overnight process. This difference may lead to lower recoveries in bloodspots compared to cord
blood. Recoveries of the standard reference materials (SRMs) were acceptable, but the SRMs were not
comparable to the low mercury concentrations seen in this study.
38
She then considered the possible biological explanations for the disparity. Both specimen types are
newborn blood collected within 24-48 hours of each other. The halflife of methylmercury in blood is ~50
days, so it’s unlikely that the mercury could decrease so quickly. Mercury levels in cord blood and
newborn spots should be very similar. So staff explored the idea of whether hematocrit—the percent of
red blood cells in a unit of blood—could be involved. The higher mercury concentrations seen in cord
blood compared to maternal blood have been attributed to the fact that hematocrit is higher in the
developing fetus than the mother, so we hypothesized that this could be involved here as well.
Staff assessed the hematocrit in a sample of cord blood from each infant. Staff then compared the
hematocrit with mercury levels in the cord blood and bloodspots gathered from the 16 infants with
detectable mercury. Hematocrit was not correlated either with cord mercury or with the cord-NBS
mercury ratio. A comparison of samples with low v. high hematocrit showed that the correlation
between cord and NBS mercury was similar when tested using Pearson correlations on log-transformed
values. (Spearman correlations were different, but Jessica said staff decided to primarily use Pearson
results because these met the statistical assumptions, and the test has greater power.) In regression
models of cord v. spot mercury, adding hematocrit to the model did not appreciably change the
estimate or the R2 value, nor was hematocrit a significant predictor of cord mercury.
These results, Jessica said, are limited by the small sample size. We don’t know for sure whether
hematocrit may explain the higher mercury levels in cord blood because we don’t have hematocrit
measurements in spot blood and cannot make this direct comparison. Hematocrit may explain the
variability of mercury levels in cord blood v. newborn bloodspots, but this project did not see evidence
for this. More work is necessary to resolve the question.
Jessica gave a few other updates about the statistical analysis. Results using data from questionnaires
administered during the mothers’ third trimester were similar to those using data from first trimester
questionnaires: reported number of seafood meals per week was positively associated with cord
mercury. Jessica also discussed the correlation statistic used, and said that, after more exploration, staff
decided to use the Pearson test on log-transformed values; other papers in the literature use this
approach, and the test has greater power. The overall correlation is stronger using this approach than
the Spearman test (r=0.82 compared to 0.58). Because the main message from these findings is that
measuring mercury in NBS may underestimate fetal exposure (as measured by cord blood), staff decided
to flip the cord-to-NBS ratio to present the NBS-to-cord ratio instead in preparing the manuscript. The
NBS-to-cord ratio is 0.85, compared to the cord-to-NBS ratio of 1.3.
Finally, Jessica showed a slide that put these cord blood mercury results in the context of other studies
(Table 1). The slide summarized the results of 7 studies in the US and Canada, including the MDH-UMN
project. The MDH-UMN project’s small population primarily comprised well educated Caucasian
women, and only one child had a mercury level above the 5.8 µg/L reference limit. Our results were
similar to studies in Rhode Island and Quebec, but lower than studies in a number of other places,
including New York City and Hawaii, where much higher percentages of participants had levels above 5.8
µg/L. Results of the other studies indicated that higher cord blood mercury levels occurred more often
among babies of women of minority or foreign birth, including African American and China-born Asian
women.
39
Table 1. Hg in cord blood: other studies
Study
Population
n
MDL
%
ND
GM
(µg/L)
95th
%>
Median
Max
%ile
5.8
(µg/L)
(µg/L)
(µg/L)
µg/L
MDH
2012
Women receiving prenatal care
at a clinic in Minneapolis
52
0.3
35%
0.6
0.7
Rhode Island
Women giving birth at a
community hospital in
Pawtucket, RI
538
0.2
43%
0.5
African American participants
46
Women giving birth at 3
hospitals within 2 miles of the
WTC site
280
China-born Asian participants
83
Baltimore
2004-05
Births at Johns Hopkins
Hospital (70% African
American)
294
0.3
Quebec
Women receiving prenatal care
at a clinic in SW Quebec
92
0.2
Brooklyn
2007-09
Women receiving prenatal care
at a clinic in Brooklyn (41%
Caribbean/ West Indian, 43%
African American)
78
0.2
Hawaii 200405
Women giving birth at hospital
in Honolulu (8% white)
188
NYC 2001
Study
Population
n
MDL
% ND
GM (µg/L)
Media n (µg/L)
95th %ile (µg/L)
Max (µg/L)
% > 5.8 µg/L
MDH
2012
Wome n
receiving
pre natal
care at a
clinic in
Minne apolis
52
0.3
35%
0.6
0.7
3.5
8.3
2%
Rhode Isla nd
Wome n
giving birth
at a
community
hospital in
Pawtucket,
RI
538
0.2
43%
0.5
39. 9
7%
Africa n
American
participa nts
46
Wome n
giving birth
at 3
hospitals
within 2
miles of the
WTC site
280
63
32%
NYC 2001
3.5
8.3
2%
39.9
7%
32%
2.1
0.2
0.3%
2.4%
4.4
4.3
63
12.6
15.8
63
1.4
1.4
3.0
(90th)
0.6
1.6
2.1
4.8
(mean)
16.5
9.2
2%
16%
20
28%
2.1
0.2
0.3%
2.4%
China- born
Asia n
participa nts
83
Baltimore 2004-05
Births at
Johns
Hopkins
Hospital
(70%
Africa n
American)
294
0.3
Que bec
Wome n
receiving
pre natal
care at a
clinic in SW
Que bec
92
0.2
Brookly n 2007- 09
Wome n
receiving
pre natal
care at a
clinic in
Brookly n
(41%
Caribbean/
West
India n, 43%
Africa n
American)
78
0.2
Hawaii 2004- 05
Wome n
giving birth
at hospital
in Honol ul u
(8% white)
188
4.4
4.3
12. 6
15. 8
1.4
1.4
3.0 ( 90t h)
0.6
1.6
2.1
4.8 (mea n)
63
16. 5
9.2
2%
16%
20
28%
40
MDH
2012
Wome n receiv ing pre natal care at a clinic in Minnea pol is
52
0.3
35%
0.6
Rhode Isla nd
Wome n giv ing birt h at a community hospital in Pawt ucket, RI
538
0.2
43%
0.5
Africa n American participa nts
46
Wome n giv ing birt h at 3 hospita ls w ithin 2 mile s of t he WTC site
280
China- born A sia n pa rticipant s
83
Baltimore 2004-05
Births at Johns Hopk ins Hospital ( 70% A frica n American)
294
0.3
Que bec
Wome n receiv ing pre natal care at a clinic in SW Que bec
92
0.2
Brookly n 2007- 09
Wome n receiv ing pre natal care at a clinic in Brookl yn ( 41% Caribbe an/ West India n, 43% A frican American)
78
0.2
Hawaii 2004- 05
Wome n giv ing birt h at hospital in Honol ul u (8% w hite)
188
NYC 2001
0.7
3.5
8.3
39. 9
7%
32%
2.1
0.2
0.3%
2.4%
4.4
4.3
63
12. 6
15. 8
63
1.4
1.4
3.0 ( 90t h)
0.6
1.6
2.1
4.8
(mean)
16. 5
9.2
2%
16%
20
28%
41
42
The project’s next steps include




Submitting a manuscript to the journal, Environmental Research, as a “Report from the Field.”
Learning more about laboratory investigation of spot v. cord differences in mercury analyses.
Speciating a subset of the cord blood samples to identify the proportion of methylmercury (from
fish) and the proportion of inorganic mercury (from other sources, such as metallic mercury or
mercury in skin lightening creams).
Eventually, a summary of the project results will be placed on the MN Tracking website.
Jessica then asked panel members to consider the following questions:


Can the panel suggest other ideas about why mercury levels were higher in cord blood than
in NBS?
Have we adequately explored the role of hematocrit or other factors in this relationship?
Discussion
The discussion was short, to provide more time for a joint discussion of all of the mercury presentations
together. Bruce Alexander asked whether laboratory staff could create a blood spot with cord blood,
and laboratory chemist Betsy Edhlund said that they could. Bruce added that hematocrit might be a red
herring, but that we need to know whether the blood spot can characterize the mercury in the cord
blood.
MDH Assistant Commissioner Aggie Leitheiser asked whether “seafood” in the survey applied to fish in
general. Jessica explained that the survey was designed before the joint project existed and asked only
one general question about seafood.3 She added that the lack of specificity about the meaning of the
term, seafood, is a limitation in the collaborative study.
During her presentation, Jessica had mentioned that delayed cord clamping during cord blood collection
might affect hematocrit. Pat McGovern asked Jessica to tell the group more about this. Jessica
explained that, until recently, the standard of care in a birth was to clamp and cut the umbilical cord
immediately after the birth. Some clinicians are now waiting longer before clamping the cord to allow
more blood to flow into the infant. Waiting even 2 minutes or more can raise the iron level in the baby.4
3
Exact wording for the question was: “At how many meals [in a typical week since you became
pregnant] did you consume seafood?” Respondents answered with the number of meals per week.
4
JAMA. 2007;297(11):1241-1252 (original report). The placenta and umbilical cord can contain up to
200 ml of blood, which contains hematopoietic stem cells as well as important reserves of iron for the
infant. According to the Journal of the American Medical Association, roughly 20-40 ml of blood can
43
Pat McCann asked, is cord mercury actually higher than spot mercury, given the strong Pearson
correlation results? Jessica answered that the two blood measures are strongly correlated, but that
doesn’t mean they reflect the same absolute amount. These findings are preliminary, but it looks as
though the two measures are strongly correlated, and cord mercury is higher than spot mercury (this
difference is statistically significant). Pat McGovern then commented that the key to the question is for
the laboratory to test cord bloodspots.
A recruitment protocol for pregnant women and their newborns
Ruby Nguyen, collaborator and UMN principal investigator in the MDH-UMN Pregnancy and Newborn
Exposure Study, reviewed key elements of the way The Infant Development and Environment Study
(TIDES) protocol was adapted to recruiting and obtaining consent from pregnant women in the MDHUMN study (Note: the full TIDES Recruitment Protocol is in both the June and October 2013 Advisory
Panel books). The MDH-UMN study was an add-on to the original Minnesota TIDES. The participants
had been in TIDES since their first trimester of pregnancy and knew the TIDES staff. Thus, when TIDES
staff met with the study participants at their third trimester clinic and TIDES visit, the women knew and
trusted the staff and were willing to learn about the new study and to sign consents for themselves and
their babies.
In addition, TIDES staff already had developed good relationships with the hospital staff. TIDES study
staff prepared and delivered all of the MDH-UMN study specimen collection kits. Delivering clinicians
collected the cord blood, and hospital staff who collect newborn screening spots collected extra spots
for the study. TIDES staff also provided gift cards as compensation to participants. New studies in other
hospitals and clinics would have to develop these relationships from the start.
Ruby identified several potential barriers to recruiting pregnant women that could affect future studies
of the distribution of mercury exposure in Minnesota’s newborns. She listed five factors in the TIDES
effort that made the MDH-UMN collaboration work well and then listed likely hurdles that could arise in
new studies.
Table 2. Important Factors in Recruitment and Consent in Studies of Pregnant Women
TIDES
•
•
Future Studies
Relationship with women
Relationship with clinic and hospital
•
•
“Cold contact”
New relationship with clinics and hospital
‘pulse’ from the placenta to the newborn during birth. Current industry benchmarks for cord blood
collections are a minimum of 50 ml of blood. Given the amount of blood likely to flow out of the
placenta at the time of birth, there is typically plenty to be stored for later use. Retrieved 12/9/13;
Source: Delayed Clamping and Cord Blood Banking: A Parent’s Guide
44
TIDES
Future Studies
•
•
•
Population generally willing to participate
Access to birth records in real-time
On-going contact for notification of results
•
•
•
•
•
Relations hip with women
Relations hip with cli nic and hospital
Population generally willing to participate
Acces s to birth records in real -time
On-g oing contact for notification of results
TIDES
•
•
•
Population of unknown willingness to
participate
Multiple birth records system
Address at time of consent for notification
•
•
•
•
•
“Col d contact”
New relationshi p with clini cs and hos pital
Population of unknow n willingnes s to participate
Multiple birth records syste m
Address at time of cons ent for notifi cation
Future Studies
Future studies of interest to EHTB would seek more diverse populations than those in TIDES. To find
diverse populations, MDH staff would have to contact and build relationships with hospitals and clinics
in the Metro and outstate. Noting that recruiting populations that are not predominantly highly
educated Caucasians can be difficult, Ruby said that some populations of minority and disadvantaged
women might not be willing to participate. She also pointed out that different hospitals often use
different systems for birth records; having no access to real-time birth records makes it difficult for staff
to prepare effectively for the cord blood collection and also means that the record does not provide an
extra check on the correct number of samples. Moreover, because people in disadvantaged populations
often change addresses, the address a participant gave at the time of consent might not be valid when
staff send out the results. To ensure that the addresses are current, staff would need to keep in close
contact with the participants. Ruby suggested that MDH approach multiple clinics. In the Metro, she
recommended approaching Hennepin County Medical Center and Allina physicians who are tied closely
to UMN research programs.
Discussion
Pat McGovern asked, if a cord blood study involved several different hospitals, could the women
themselves be empowered to request the attending physicians to collect cord blood at the birth? Ruby
Nguyen replied that, in TIDES, some women who were in labor were sent to other hospitals because the
birthing rooms at the study hospital were full. In that case, she explained, even if we sent a collection
kit for the cord and newborn spots, we could not know whether the other hospital could handle the
cord blood properly. The biggest problem would be in storing the cord blood sample at – 20oC, rather
than the blood collection itself. Bruce Alexander wondered whether women in labor might forget to
bring the kit in their haste to reach the hospital. Ruby replied that, before they go into labor, women
often pack a travel bag to bring to the hospital when labor begins. Studies could give the women a bag
with the study logo, a cord blood collection kit, and instructions for specimen collection and handling.
In the MDH-UMN study, Bruce asked, how much time elapsed between the time the blood was collected
and the time the study staff could send the results to the mothers? Ruby replied that the study looked
at babies born between June and January. The results were sent in batches and the time interval ranged
from three to nine months. Bruce said that he was concerned that someone else might be at the
address a participant had given when she entered the study. He suggested staff should track the
addresses to ensure that the participants receive the results. Jessica Nelson said, this issue is the same
for all biomonitoring results, and suggested that using something like certified mail might add an extra
layer of security.
45
Pat McGovern asked how much the study used social media technology to communicate with the
participants. Ruby replied that TIDES did not use much because they saw the participants frequently,
but the study did use email to let potential participants know about the meetings.
Public Health Laboratory Progress Report
Metals chemist Betsy Edhlund briefly described the MDH Public Health Laboratory’s responsibilities and
progress in developing and validating methods for measuring mercury and other metals in newborn
blood spots and in cord blood. The PHL is a Level 1 laboratory in the federal Emergency Response
Network. In this role, the PHL’s metals laboratory has been adding more metals to its list of analysis
methods and is taking part in emergency response exercises that require the lab to analyze 500 samples
in as short a time period as possible (hours, rather than days). The laboratory also participates in
proficiency tests (PTs) three times per year. The laboratory also provides the metals analyses in both
blood and urine for MDH biomonitoring projects.
46
Table 3. Current MDH PHL Metals Laboratory Responsibilities
•
•
•
Laboratory Response Network
• Blood Metals, Urine Metals, Arsenic Speciation
• 3 PTs/year
• Emergency Response and biomonitoring
EH
• GLRI – 6 analyses in house (more than 20 analytes)
• Fish are Important for Superior Health – blood metals, fatty acids
EHTB
• TIDES
• National Children’s Study (Supplemental Methodological Study: Newborn Mercury
Biomarker Validation)
• Riverside bloodspots
• Future projects
•
•
1
Currently, the laboratory has only one instrument for analyzing metals in blood and urine, and the
instrument is used for both biomonitoring and emergency response. But the lab has updated and
validated metals methods for blood and urine for both uses and has expanded the urine method to 16
metals. The laboratory has been awarded an Association of Public Health Laboratories (APHL)
fellowship. This person will assist with clinical testing and biomonitoring support over the term of the
fellowship. The lab may also obtain another instrument for metals analysis. Both of these will greatly
enhance the laboratory’s capacity for metals analysis.
In comparing the advantages and disadvantages of analyzing mercury—and possibly other metals—in
cord blood versus newborn blood spots, Betsy reviewed the following factors:
Table 4. Advantages and Disadvantages of Cord Blood and Newborn Blood Spots
Whole blood






Gives sufficient amount to measure Hg,
Cd, Pb
Standard reference materials (SRMs) are
available
Standard network-wide method
Regular PTs
Simpler method
Homogeneous sample
Blood spots




In MN, lab now can do Hg only, but Utah also
does Cd & Pb
Chemists must assume the amount &
homogeneity in the very small blood sample
Less efficient sample throughput
More complicated extraction process
47
Whole blood
Blood spots


Requires more storage space
Easier to store (require little storage space)
The bottom line, Betsy said, is that blood spots take more preparation and data analysis time.
Discussion
Pat McGovern asked Betsy to list the metals that the lab can measure. They are:
Table 5. Current PHL Metals Suite
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Antimony
Arsenic
Barium
Beryllium
Cadmium
Cesium
Cobalt
Lead
Manganese
Mercury
Molybdenum
Strontium
Thallium
Tin
Tungsten
Uranium
Currently, staff are halfway through the methods validation of all these metals and expect to finish all of
them in the next few weeks.
48
Table 6. Comparison of Newborn Specimens for Ongoing Mercury Biomonitoring
NBS (Newborn Screening Bloodspots)
Umbilical Cord Blood
Advantage: Specimens from a statewide MN
population. Low cost. Bloodspots stored for 71
days, but with informed consent, may be stored &
used for research for up to 18 years.
Disadvantage: Cord blood is collected in hospitals/
birthing centers with advance informed consent.
Higher cost: contracts with hospitals, staff training,
collection kits, collection & transport protocols.
Disadvantage: Spot blood volume is limited. Lab
analysis can determine total mercury only. Quality
control is limited.
Advantage: Large volume of whole blood allows
more analyses; e.g., a metals suite (Pb, Hg, Cd).
Disadvantage: NBS have a small blood volume.
Detection limits for mercury are less sensitive than
those for cord blood. Only the highest exposures
(e.g., 75th or 95th percentile) can be reported.
Advantage: A more sensitive detection limit for
mercury allows staff to describe a wider range of
exposures, from low to high.
Disadvantage: Spots have a small blood volume,
so staff cannot distinguish methylmercury (from
fish) from inorganic sources of mercury (e.g., skinlightening creams)
Advantage: Greater blood volume & lower detection
limit allow staff to analyze methyl- & inorganic
mercury to identify exposure sources. MDH can work
to prevent exposure.
Neutral: Difficult to achieve a representative
sample from the population. Spots are collected
for nearly all births, so MDH could contact mothers
by mail to ask consent for testing, but participation
is low. Hospital/clinic consent may improve
participation.
Neutral: Difficult to achieve a population-based
sample. Participation rates for consent obtained
prenatally in hospitals/clinics vary; the National
Children’s Study Alternative Recruitment Study
obtained nearly 80% participation through
hospitals/clinics. Problems during delivery may
prevent hospital staff from collecting cord blood.
Disadvantage: NBS analysis method at MDH is not
yet a published method.
Advantage: Published and externally validated
methods.
Disadvantage: No reference level for total mercury
exposure in newborn bloodspots has been
established to date.
Advantage: Exposure measured with cord blood
specimens can be compared to published reference
levels.
49
NBS (Newborn Screening Bloodspots)
Umbilical Cord Blood
NBS (Newbor n Scree ning Bloods pots )
Umbili cal Cor d Blood
Advantage : Speci men s from a statewide M N population. Low cost. Bloodspots stored for 7 1 days, but with infor med co nsent, may be store d & used for resear ch for up to 18 years.
Disadva ntage: Cord bl ood is colle cted in hos pitals/ birthing centers with adva nce infor med consent. Hig her cost: contracts with hospitals, staff traini ng, colle ction kits, collection & transport pr otocols.
Disadva ntage: Spot blood volume is limite d. Lab a nalysis ca n determi ne total mer cury only. Quality control is limited.
Advantage : Large volume of whole blood allows more analyse s; e.g., a metals suite (Pb, Hg, Cd).
Disadva ntage: N BS have a s mall blood volume. Dete ction li mits for mercury are less sen sitive than thos e for cord blood. Only the highest e xposures (e.g., 7 5th or 95th perce ntile) can be re ported.
Advantage : A more se nsitive dete ction limit for mer cury allows sta ff to des cribe a wider range of e xposures, from low to hig h.
Disadva ntage: Spots have a s mall blood volume, so staff cannot disting uish methylmercury (from fi sh) from inorga nic s ources of mer cury (e.g. , skin-lighte ning crea ms )
Advantage : Greater blood volume & lower dete ction limit allow sta ff to a nalyze met hyl- & i norgani c mer cury to ide ntify expos ure sources . MDH ca n work to prevent e xposure.
Neutral: Di ffi cult to achieve a represe ntative sample from the population. Spot s are colle cted for nearly all births, s o MDH could contact mothers by mail to ask consent for testing, but participation is low. Hospital/cli nic consent may i mprove parti cipation.
Neutral: Di ffi cult to achieve a population -ba sed sa mple . Participation rates for consent obtained prenatally in hos pitals/cli nics vary; the National Chil dren’s Study Alternative Recruit ment Study obtained nearly 80% participation throug h hospitals/ clinics. Proble ms during delivery may prevent hospital staff from colle cting cord blood.
Disadva ntage: N BS analysis method at MDH is not yet a publishe d met hod.
Advantage : Publi shed a nd e xternally validated met hods.
Disadva ntage: N o refer ence level for total mercury e xposure in newbor n bloods pots ha s bee n establis hed to date.
Advantage : Exposur e meas ured with cord blood spe cimens can be compare d to publishe d refere nce levels .
Choice of Mercury Specimens: Bloodspots v. Cord Blood
Jean Johnson reviewed the advantages and disadvantages of both newborn bloodspots (NBS) and cord
blood for measuring mercury and other metals in newborn blood (Table 6). A more detailed table is in
the Advisory Panel background book for the October 8, 2013 meeting. She asked for the panel’s
recommendation for the specimen type that best meets the criteria in Minnesota Statutes5 for a
biospecimen “that most accurately represents body [prenatal or newborn] concentration of the
chemical of interest.” She asked panel members to consider the availability of each specimen (cord and
newborn spot blood), ease and cost of collection, the ability to compare and interpret results with other
studies and reference groups, the capacity to conduct additional analyses with the same specimen, and
laboratory quality assurance and validity issues.
Jean then asked the panel to take a vote in the following question:
Which specimen type should MDH collect for ongoing biomonitoring of mercury in newborns to meet
the public health goals below?


5
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
Minn. Stats. 144-995-144-998.
50

To identify what sources, in addition to fish consumption, contribute to the exposure
In funding EHTB’s biomonitoring program in 2013-14, she explained, the Minnesota legislature’s intent
was for MDH to follow up on the findings of the Mercury in Newborns in the Lake Superior Basin6
project to learn whether other populations were similarly exposed in other parts of the state. Newborn
bloodspots analyzed in the Lake Superior project indicated that 10% of Minnesota newborns tested in
the study had total mercury levels over 5.8µg/L, the Environmental Protection Agency’s reference limit
for methylmercury exposure. In addition, the high levels peaked in the summer months, which
suggested that the source was probably methylmercury in fish that the mothers had eaten.
Jean also reminded panel members of a new barrier to using newborn bloodspots in similar studies.
Under recent legislation in Minnesota, storing and using newborn bloodspots for any purpose other
than newborn screening now requires the mother’s consent within 71 days of the birth.
Discussion
The panel’s discussion revolved around the issues below:





Ability to obtain consent from participants
Ability to report results to parents, crucial for newborns with elevated mercury levels
Ability to collect and analyze specimens with limited finances
Potential to contribute to better scientific understanding
Potential for public health assessment of exposure (to measure the extent to which newborns
in different parts of the state are exposed to potentially harmful levels of mercury during
prenatal development)
Ability to obtain consent from participants
Panel members discussed Minnesota’s data practices requirements first, turning to Assistant
Commissioner Aggie Leitheiser to learn more about the 2006 legislation and its effects on public health
practice. Aggie explained that MDH’s newborn screening program tests newborn bloodspots to identify
congenital disorders that could pose health and developmental challenges if they are not addressed
early in a child’s life. The 2006 law followed a lawsuit that claimed that MDH was collecting newborn
spots and using them for research without consent.
This legislation has raised barriers to using newborn spots for such projects as tracking mercury
exposure in newborns. The requirements allow the newborn spots to be stored for 71 days, after which
they are destroyed. During the 71 day period, the spots cannot be used for any purpose other than
newborn screening, except with special consent. Test results can be stored for two years before they
6
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.
51
are destroyed. Spots retained with consent to allow research may be retained for 18 years or “until I
request otherwise,” but to date, few mothers (< 1%) have been approached for consent and agreed to
that long period of time.
Jean Johnson suggested that staff could obtain consent prenatally, or that staff could send out letters
shortly after births to obtain consent within the 71-day period. Jean wasn’t optimistic about the
likelihood of getting consents within that window of time and meeting recruitment goals. Pat McCann,
principal investigator of the Mercury in Newborns in the Lake Superior Basin project, said that the Lake
Superior Basin study’s requests for consent to use newborn spots were returned about five weeks after
the consent request (or 8 weeks after the birth).
Lisa Yost asked whether some event had occasioned this lawsuit, but Aggie answered, no. MDH
complies with federal definitions of public health surveillance v. research, she said, but a group of
people, concerned that babies’ genetic information could be used inappropriately by the government,
filed the lawsuit. Obtaining consent can be expensive and difficult, Aggie commented. Alan Bender
noted that requiring consent for collecting public health data on the population could make it difficult to
do effective surveillance.
Currently, MDH is writing a report arguing for longer storage and research options in future newborn
screening spots, and expects to need informed consent from the mothers for these options.
Ability to report results to parents
Bruce Alexander asked whether MDH would be able to contact parents of babies who were found to
have high mercury exposures. If we measure mercury in cord or newborn bloodspots, he said, we will
find high mercury levels in some babies. Would that concern influence the decision to choose cord
blood v. newborn spots? Aggie Leitheiser replied that MDH tests newborn spots in routine newborn
screening now and has a protocol for contacting parents. Ruby Nguyen said that the MDH-UMN study
reported the cord blood results to the parents and also enabled parents concerned about their child’s
exposure to consult with MDH’s environmental health physician. Jean Johnson added that, so far, MDH
has not reported any newborn blood spot results to the parents.
Lisa Yost asked, isn’t that because you found only one baby with a high mercury level in the MDH-UMN
study? Yes, said Jean, but 10% of the babies tested in the Lake Superior Basin project had high mercury
levels in their newborn spots. Because the Lake Superior study anonymized the spots,7 MDH was unable
to contact the parents of babies born with high mercury levels. Lisa noted that part of the reason for
anonymizing the spots was that, at the time, we didn’t know what the laboratory report might mean.
Utah’s state health department is doing a surveillance study of cadmium, lead, and mercury levels in
newborn bloodspots, Jean said, but MDH does not know whether the department is sending the results
to the parents. But in any future project, whether in newborn spots or in cord blood, MDH would notify
7
The laboratory technique for mercury in newborn spots was considered experimental at the time.
52
the parents. Any baby with a mercury level of 5.8µg/L and above should have follow up. Alan Bender
agreed, saying that it’s hard to believe that MDH would conduct a public health assessment of exposure
in newborns without contacting the parents if we identified a problem. If you find an elevated reading,
he added, aren’t the results from either of the two specimens just indicators for further follow up with
the participants? In either case, finding an elevated mercury level in a newborn requires follow up.
Ability to collect and analyze specimens with limited finances
Both David DeGroote and Jill Heins-Nesvold asked about the differences in cost between cord blood
collection and analysis v. newborn spot collection and analysis. MDH will have to consider both costs.
Pat McGovern noted that the cost of cord blood collection would depend on whether hospitals bill for
the collection. Sometimes, she said, hospitals interested in doing research will collect the cord blood as
an in-kind contribution to a study; others may not. Betsy Edhlund said that it is cheaper to measure
metals in cord blood than in spots. Speciating mercury8 in the cord blood raises the analysis cost, but
the longer time to prepare and run bloodspots through the lab instrument costs more than measuring
metals in whole blood (cord blood). Overall, however, she thinks the two analyses may be fairly
comparable in cost.
Aggie Leitheiser asked, how many mercury projects do you envision? Jean Johnson replied that EHTB
has $268,000 each year for mercury assessment for Fiscal Years 2014—2015. Assessing mercury
exposure in Minnesota newborns is only one project, but will need to be carried out in multiple sites.
David asked whether staff had any sense of the number of samples needed to address the question of
newborn spots versus cord blood samples. Jean replied that the program had budgeted for 600
newborn spots.
Potential for better scientific understanding v. public health assessment
The discussion then turned to the scientific and public health value that each kind of specimen offered.
Pat McGovern urged the staff to keep pushing the science to determine whether the newborn spots
provide a robust, valid, reliable index. She said that more research with matched cord blood: newborn
spot pairs would help to clarify this question. Bruce Alexander argued for using newborn bloodspots to
assess mercury exposure in newborns across Minnesota. Long-term, this would build a framework for
tracking routine measurements of mercury exposure in Minnesota newborns. In the end, the decision
hinged on the purpose of the project and on the populations of interest.
Arguments for cord blood focused on two factors.

8
First, hospital staff can collect 4 to 40 ml of cord blood. The amount of blood is enough to allow
the laboratory to speciate mercury, measure other analytes, such as cadmium, lead, and
manganese, and to use the blood to further test the results found in the MDH-UMN study.
Speciation identifies the proportion of methylmercury v. inorganic mercury.
53

Second, cord blood has been used to assess mercury in many studies of newborns, so MDH can
compare its results with those of published results.
Lisa Yost suggested that cord blood might be more reliable for a targeted study of vulnerable
populations. Alan Bender agreed that cord blood is the standard. If the program must choose, and if we
are unsure of what the data mean, he said, the specimen should be cord blood. Lisa advised the
program to look at other studies and to decide which of the two specimens to use based on which
populations would be more willing to consent to one specimen or the other.
Pat McGovern suggested that the program could go forward with cord blood in the Metro and then
address the question of the relationship between cord v. newborn spots in two years. Lisa suggested
that staff focus on groups that are likely to be exposed. Although cord blood is more reliable, she said, if
we ask for consent, we may be able to get both cord blood and newborn bloodspots. Jean Johnson said
that, with Ruby Nguyen’s help, we can reach diverse populations in the Metro area to determine which
are being exposed. Pat added, given the health disparities in minority and disadvantaged populations,
this is important.
Geary Olsen asked, what target populations would be recruited in these projects, and how would EHTB
staff recruit them? Jean said that staff would present target populations at the next Advisory Panel
meeting, in February. In the meantime, staff would talk with hospital staff and find out where we would
have viable partners. Geary also asked for clarification on the question the project would address. Jean
said to answer the legislature’s question: Are newborns being exposed to mercury in regions of
Minnesota other than the Lake Superior Basin? Alan Bender rminded panel members of legislative
intent— to determine whether mercury is a problem in Minnesota with the best use of the resources
you have.
Arguments for newborn bloodspots depended on four major factors clarified in the discussion:




First, newborn screening bloodspots are collected from almost all babies in Minnesota.
Second, both the Public Health Laboratory’s experience and the results of the MDH-UMN
project indicate that newborn bloodspots give reliable results at and above the EPA reference
limit for methylmercury, 5.8µg/L of blood.
Third, although MDH must obtain consent for collecting either cord blood or newborn
bloodspots, the newborn spot collection is a routine request and less expensive.
Last, the legislature funded MDH to assess mercury exposure in Minnesota to learn whether
mercury is a problem in parts of the state other than the Lake Superior Basin.
Twice during the earlier discussions, both Jean Johnson and Mary Manning, assistant director of the
Health Promotion & Chronic Disease division, had turned to the Public Health Laboratory to ask about
their confidence in the results of mercury measurements in newborn bloodspots. Both times, the
laboratory staff affirmed that they were confident of the validity of the newborn blood spot results.
These answers, plus the close correlation between cord blood mercury and newborn spot mercury seen
in the MDH-UMN study, led panel members to return to considering the role of newborn bloodspots.
Bruce Alexander pointed out that MDH already has a system for collecting newborn bloodspots. He
asked: Can MDH make use of this newborn screening system for routine public health surveillance? Are
54
we setting up a surveillance system across the state that would be able to detect and report high
mercury levels in newborns? Is this [a decision] for a long-term plan? Pat McGovern suggested that the
question of interest might determine the specimen: surveillance v. targeted study, with cord blood in
some populations, newborn spots in others.
David DeGroote said the issue is a question of analytics—should we use cord blood because it offers
better science v. how can we best answer the legislature’s question: Is mercury a problem in
Minnesota? David encouraged the panel to think beyond the Metro area. He pointed out that St. Cloud
is near the state’s largest coal-fired power plant, the Sherco Generating Plant, which in the past released
much more mercury than the other, smaller, coal-fired plants in Minnesota. [Note: The Sherco Plant is
reducing its mercury emissions in cooperation with the Minnesota Pollution Control Agency.] St. Cloud
Hospital has a strong research arm and serves a large population of Somali and Hmong residents who
may be affected by mercury, he added, so staff might want to contact St. Cloud Hospital.
Bruce Alexander concurred with the need for a more statewide sample. Newborn bloodspots, rather
than cord blood, may be a better way to answer the legislators’ question: Are newborns exposed to
high levels of mercury exposure in other regions of Minnesota? Spots could give a more efficient sample
from a larger portion of the state. Even given the hurdle of having to obtain informed consent, he said, I
still think the legislature’s question about the distribution of high mercury exposure in Minnesota will be
answered better by measuring newborn bloodspots. Collecting cord blood would involve far more work,
from recruiting and consent to collection, storage, and shipping from outstate Minnesota.
Lisa Yost asked, am I right that the spots have a detection limit that’s adequate to detect 5.8 µg/L and
above? Jean Johnson answered that bloodspots reliably identify newborn exposure at the 5.8 µg/L limit
and above, and results above 5.8 µg/L should have follow up. In that case, Lisa said, the spots serve the
purpose of identifying babies with a mercury problem. A wider distribution of data may not be needed
for this purpose. In addition, both cord blood and newborn spot samples involve a consent issue, but if
what you want to get a better picture of the overall state population, the availability of the bloodspots is
very attractive.
Ruby Nguyen suggested that new projects could use either leftover newborn screening spots or ask for
consent to collect an extra spot with the standard newborn screening spots. In the MDH-UMN
collaboration, staff asked pregnant women to consent to the collection of an extra blood spot on special
filter paper. The advantage was that the collection was done through the normal newborn screening
process, with the addition of an extra spot. She also noted that some leftover spots might be on
contaminated filter paper.
Geary Olsen suggested that the best access to cord blood is [likely to be] local and suggested that the
program collect and analyze cord blood locally and newborn bloodspots statewide. Pat McGovern
suggested that the program might collect cord blood in a subsection of the newborn spot study to
answer the scientific question at the same time. But Bruce Alexander disagreed, saying that adding cord
blood to the 600 newborn spot samples would likely be too expensive.
Lisa Yost joined Bruce in arguing for using newborn bloodspots. With either specimen, she said, you
need to spend the funds to get consents that are representative of Minnesota populations. I think we
know that bloodspots are good enough to use [for a statewide study]. The real barrier is the consent.
55
The bloodspots under-predict the exposure, but not dramatically, and bloodspots are both valid and
cheaper. Moreover, Alan Bender pointed out, if the project limits the inferences it can draw, the data
would be sound for the purpose.
After first asking panel members which specimen they thought would best answer the legislature’s
question, Pat McGovern asked panel members for a motion and a vote. Bruce Alexander proposed the
motion: Staff should pursue the use of newborn bloodspots to answer the legislature’s question: Is
mercury exposure in newborns a problem in Minnesota [outside of the Lake Superior Basin]? Pat
McGovern seconded it, and the vote was unanimous in favor.
After the vote, Bruce proposed that it would be useful to pursue the cord blood: newborn bloodspot
validation in some arena. Pat seconded that motion, saying that the program could look for external
resources with the support of the panel. She asked for a vote on the motion, If resources exist, the
program should further explore the cord: newborn blood spot correlation in a new study. This vote, too,
was unanimous in favor.
Biomonitoring Summit—Reflection & Next Steps for Sustainability
In June, MDH partnered with Wilder Research to sponsor a State Biomonitoring Summit, held at the
Dakota Lodge in St. Paul. Nearly 100 participants attended, representing state and local government
agencies, academic institutions, private and non-profit businesses, health laboratories, advocacy groups
and the Minnesota Legislature, along with leaders from state biomonitoring programs in California,
Washington, and Wisconsin. The Summit provided a platform for sharing the program’s
accomplishments since Minnesota’s EHTB program began in 2007, and for learning from other states’
experiences and envisioning the future.
In the afternoon sessions, participants were asked to consider questions about the sustainability of
Minnesota’s Biomonitoring Program. The 2007 legislation that created the EHTB program had based the
program’s funding on an ongoing appropriation. In 2011 and again in 2013, the legislature changed that
appropriation to funding for specific, limited projects over each two-year period (FY 2011-12 and FY
2014-15), with no assurance for continuing state support beyond FY 2015. As speakers from other
states made clear in their own presentations, this situation is not unusual.
Barbara Deming, a consultant from Minnesota Management and Budget’s Management Analysis
Division, reported on the outcomes of the Summit and on EHTB’s proposed sustainability planning. She
noted that the 2007 legislation that established the program had directed MDH to plan and implement
an ongoing biomonitoring program for the state of Minnesota. The program’s 2013 Report to the
Legislature (EHTB 2013 Report to the Legislature) put forward a vision and strategies (see p. 32, AP
background book) that included protecting future generations by focusing resources on biomonitoring
populations that are most vulnerable to chemical exposures, including pregnant women, their babies,
children, and disadvantaged communities.
At the Summit, Barbara reported, participants demonstrated a high level of interest, both in the state
and among other states. Participants said that the Summit showed the value of biomonitoring through
progress in identifying exposures and addressing public health concerns. They saw biomonitoring as a
tool to be used in identifying and understanding health disparities and social determinants of health,
and as a tool to help us understand where to focus our public health interventions. The overall message
56
from participants was that the program meets a need in public health and needs to develop financial
sustainability. Barbara then presented the next steps: a three-part plan for addressing the program’s
sustainability:
1. Funding strategy: In accordance with the “duties of the advisory panel” as described in the
Minnesota’s legislation, form a task force to explore potential funding for an ongoing
biomonitoring program, including federal, state, foundation, and business sources.
2. Evaluation strategy: Evaluate and describe the impact of biomonitoring as a tool for health
improvement in Minnesota.
3. Communication (marketing/PR) strategy: Develop multiple approaches to raising the visibility
and promoting understanding of the public health value of a state biomonitoring program.
Barbara introduced Kris Van Amber, another consultant from MAD who will work closely with staff and
will lead the biomonitoring task force. Kris said her role is to work with a task force from the panel to
identify funding and develop strategies to sustain the program.
Panel members were invited to discuss and comment on the Summit Report and recommended
strategies, and to consider these questions:


Which strategies are likely to be most successful for sustaining a state biomonitoring program?
Would you be willing to serve on a task force to provide additional guidance to staff as we
explore potential new funding sources?
Discussion
Pat McGovern applauded the strategy, saying that the three tasks—funding, evaluation, and
communication are right. “I think you nailed it with these three issues.” The funding is the key factor,
but knowing how to frame your message with strong communications must have a role.
Alan Bender’s view was that some of these strategies are out of our hands. We need to capture
people’s imagination. Stories will help keep the program going—stories capture people’s imagination.
Jill Heins-Nesvold said, I think the question is too big – it starts with, what’s the plan for addressing
sustainability. Sustainability of what? Are we talking about the data portal, special research projects, or
are we looking at public health surveillance? I think we’re looking at too large a question. We need to
break it down into sub-questions and then determine what the strategies are to sustain the program’s
components.
Kris Van Amber answered that the work of this group will be doing some of that discovery,
understanding what kind of financially sustainable programs and models are out there. Also, is this a
specific issue of funding? Part of this is exploring sources of funding, but we also need to understand
who the stakeholders are.
Bruce Alexander said that the funding strategy would be huge, so the program will have to develop it
piecemeal. But the communications, public relations, and marketing—getting resources for that – may
be the way to begin. Think about the process for getting consent, for example. If health providers
aren’t aware of this program and why it is valuable, and if they don’t know why they should advise their
patients to consent, we need to educate them. We should do that by using Alan’s good stories… why
57
biomonitoring is important to individuals. A good story is better able to communicate importance than
a long report with data and statistics. Jean Johnson replied that Mary Jeanne Levitt, who handles
communications and marketing for the tracking program, will also be working with the biomonitoring
program. Before this, we’ve never taken a marketing approach with biomonitoring.
Pat McGovern wondered whether the program could identify a family or person or community whose
health behaviors or health changed because of biomonitoring. Lisa Yost suggested that the program
might create something interesting and accessible. She suggested that staff might make a UTube video
explaining public health tracking and biomonitoring.
Kris Van Amber agreed, saying you need to show the intrinsic benefit. But we will also need to be
looking at other funding as well.
Pat McGovern asked about the demands on time and the amount of work for panel members who
would work on the task force. Kris Van Amber said that, initially, task force members would come
together to look at the process, assess what the time demands might be, define the goals, and suggest
ways to accomplish them. Barbara Deming added, we could ask staff to do some research and bring
ideas and possibilities to the meetings, so more work could be done outside of the meetings for staff,
but not for panel members.
Jean Johnson summed up the dilemma: our vision is long-term surveillance, and our funding is for a
short-term project. The other states with biomonitoring programs have the same problem. Everyone is
just kind of piecing it together.
PFC3: Draft Protocol for East Metro PFC Biomonitoring III
After the 2004 discovery of contamination of East Metro drinking water supplies with PFCs, MDH and
the MPCA carried out public health interventions to reduce residents’ exposure to PFCs in their drinking
water. MDH then carried out two biomonitoring projects, in 2008 and 2010, to assess PFC exposure in
long-term residents in the area. The first round of biomonitoring documented that the residents had
higher body burdens of the PFCs compared to the general U.S. population; the second (PFC Follow-Up
Project) documented declines in the PFCs in the same group. In September 2012, the EHTB Advisory
Panel recommended that MDH continue biomonitoring for PFCs in the East Metro. Their
recommendation involved two parts:
1. Collect a third blood sample from participants in the original cohort to ensure that levels are
continuing to decline in this population, and
2. Expand the sample in the East Metro so that more people, including new residents, are
represented. Measuring PFC levels in new residents will help answer the question of whether
people who moved to the community after the public health intervention are being exposed to
elevated levels of PFCs.
Christina Rosebush and Jessica Nelson presented a draft protocol for the third round of PFC
biomonitoring. The study will test two hypotheses, said Christina.
•
Blood levels of PFOS, PFOA, and PFHxS will have declined from 2010 - 2014 in the original
cohort.
58
•
Blood levels of PFOS, PFOA, and PFHxS in new Oakdale residents will not be significantly
different than PFC levels in the US general population.
The study populations will include two different groups: one is the original group of adults whose blood
was measured for PFCs; 183 people are eligible. The second group will be 200 newer adult residents
who moved to Oakdale after the municipal water was treated to reduce PFC contamination. These
people are eligible if they moved to Oakdale and started their water service on or after November 1,
2006.
In the original group of people, the PFC analysis will measure the same 7 PFCs of interest in the original
pilot project, plus PFNA. The 2014 blood levels will be compared to the earlier levels seen in 2008 and
2010. In the new residents, MDH will compare the participants’ PFC blood levels to those seen in the
general population as measured in the Centers for Disease Control’s National Health and Nutrition
Examination Survey (NHANES).
Christina also reviewed the proposed questionnaire topics that the PFC3 project will use to learn more
about participants’ exposure to PFCs. The questionnaire will ask about a range of possible exposures,
including drinking water, diet, occupation, and product use.
Then, Jessica Nelson listed the limitations of the study of new residents:




We can’t compare new residents to the original cohort. The original participants were longterm residents, and they are older (mean, 60 years) than the new residents. Greater age is
associated with higher levels of PFCs.
The new sample does not include private well users, Cottage Grove/Lake Elmo residents, or
additional long-term residents in Oakdale.
While NHANES provides a very valuable U.S. reference population, there are some limitations.
One is timing: we will have NHANES data from samples collected in 2011-2012, while the MDH
samples will be collected in 2014. As levels of some PFCs are declining in the general
population, this time lag could affect the comparison.
Sociodemographic and other differences between people studied in NHANES and the new
resident population studied in the East Metro may also be an issue. In NHANES, PFCs are
positively associated with higher income, and it is likely that the East Metro population differs
from the NHANES population in this respect.
The proposed protocol was the approach we thought would give the clearest answer to the key
questions that people have about PFC exposures in the East Metro. Then Jessica described two
alternative approaches that staff had considered and rejected (Table 7, below)
59
Table 7. Alternative Approaches
Approach
Pro
Stratified random sample of
Oakdale residents by length of
residence (n=100 new residents
and n=100 long-term residents)


Con

Will be sure to get sufficient
number of new residents
Age match will enable valid
comparison between new
and long-term residents


Random sample of new Oakdale
residents (n=100) and new
residents of a reference East
Metro community (n=100)



Can compare new Oakdale
residents to similar MN
reference population w/o
exposure history
Avoid limitations of NHANES
comparison
Approach
Pro
Stratified random sa mple of Oakdale re sident s by length of reside nce (n= 100 new resident s and n=100 long-ter m reside nts)


Will be sure to get sufficient number of new resi dents
Age match will enabl e valid comparis on betwe en new a nd long -term re sident s
Random sa mpl e of new Oakdale re sidents (n= 100 ) and new reside nts of a re feren ce East Metro community (n=100 )


Can compare new Oak dale reside nts to si milar MN refere nce population w/ o expos ure history
Avoid limitations of NHA NES comparis on

Recruiting more long-term
residents not a priority; have
answered the question of more
PFCs associated with longer
residence
Will be hard to recruit older new
residents
More complicated to explain to
public
Given need for minimum
residency requirement, new
resident window of eligibility
very narrow (~3 years)
If we have no minimum
residency requirement, may not
have power to look at length of
residence in Oakdale residents
Con



Recruiting more l ong-ter m residents not a priority; have answere d the question of more PF Cs ass ociated with l onger residence
Will be hard to re cruit older new reside nts
More compli cated to e xplain to publi c


Given need for mini mum reside ncy req uireme nt, new resident window of eligi bility very narrow (~3 years)
If we have no mini mum residency re quire ment, may not have pow er to look at length of reside nce in Oakdale re sidents
Christina then asked the panel members to consider the following questions:
•
•
Is the proposed sampling strategy the best for answering our key questions about PFC exposures
in the East Metro?
Can panel members suggest how best to recruit new residents in the East Metro, who are less
familiar with, and likely less motivated by the topic?
Discussion
David DeGroote asked about the proposed size of the new resident population. Do you know how many
people have moved here since November 1, 2006? Christina Rosebush responded that the Oakdale
population is around 20,000 adults, and in any given year, about 10% of residents are new to their
home. We will know more about the size of the Oakdale new resident pool when we get water records
from the city.
60
You plan to send out 500 letters to get 200 participants, David continued. Will that size of population be
enough—is this a good statistical sample size? Christina answered, yes, our power calculations show
that 200 people will be sufficient to answer our primary question: Are PFC levels in the new resident
population different from those in the US general population?
Bruce Alexander said there is an issue about people moving into and out of Oakdale and other parts of
the East Metro and then moving into Oakdale again. Are there ways to track those people who might
have lived there before? Christina said that “no residence in Oakdale before 11/1/06” is an eligibility
requirement, and we will be sure to ask this in the household survey. We will also ask about all past East
Metro addresses in the questionnaire, so we will have residential history information for other towns as
well.
Bruce asked, why did you exclude Cottage Grove residents on private wells? Christina answered that it
would be difficult to get a representative sample of Cottage Grove residents who are both municipal
water and private well users. Jessica Nelson added that focusing on the Oakdale population answers the
question most directly because so many people are on city water, and there is one clear intervention
date when the city water filters were changed. Private wells are complicated because they may be
treated with different kinds of filters. Geary Olsen added that many people in Lake Elmo are now on
municipal water, so new residents there might be available for a larger population.
Geary Olsen then asked, why are you measuring PFPeA and PFHxA again? They weren’t detected in the
earlier projects, so do we need to keep testing for them? PFHxA has a halflife of 30 days, and the 4carbon chain PFBA has a halflife of 3 days, so PFPeA will likely have a halflife between 30 days and 3
days. It may be reasonable to keep PFHxA, as this is the chemistry that companies are now using, but
it’s not going to be in the water and will be coming from other sources. Levels in the water have not
been changing. Christina responded that staff will think more about this in the next phase of planning.
Geary also noted that the NHANES 2011-2012 sample included participants from Washington County.
Because that may affect the overall results, he suggested that MDH may want to check with NHANES to
see if they will provide information on the number of people involved. Jessica said she thought that this
will be important to check. Jean Johnson said that the NHANES Washington County data would be a
very useful reference to have.
Next, Geary referred to two sentences in the October Advisory Panel background book that read
“Although PFC levels in Oakdale city water are below health-based limits, low levels of PFCs are still
present in some water samples. This study will seek to determine whether this low-level exposure
results in elevated PFC blood levels.” He asked, why is MDH trying to correlate exposure to PFCs in
water to blood levels in people? The water levels are below the Health Risk Limits (HRLs), and MDH says
they’re safe for drinking for a lifetime. And when water levels are very low, ambient environmental
exposures—non-water source exposures—can become more important. Jessica Nelson answered that
we see our mandate as a question about new residents’ exposures—are there any water exposures that
might be accumulating in the body?
Geary then asked how the variation in water levels over time will be taken into account. Jessica
explained that we are using length of residence as a proxy for low-level exposure; we are not actually
using water values in any models. Low-level exposure means living in a community for
61
a longer time and presumably drinking water that has varying levels while you live there. Bruce pointed
out that there are limitations to this, e.g., you assume that everybody drinks water in the same amount
and from the same source. David added, I assume the questionnaire gets at those questions and that
you will analyze those variables along with the laboratory data. Jessica agreed that the assumption that
everyone is getting the same water all the time is a big one. Jean said that staff will change the wording
in the project protocol to clarify that the analysis will not involve water concentrations, but will use
length of residence as a proxy for water exposure.
Geary commented that the decline we saw in blood levels from 2008 to 2010 followed the
pharmacokinetic data well, and that the third time point should do the same. For each individual in the
original cohort, he suggested that staff predict ahead of time what blood values will be in 2014 based on
pharmacokinetic data. Then, when we have the results, we can compare these predictions to the actual
measured values. If past water exposure is still the main source, you should be able to predict the
participants’ levels closely.
Pat McGovern pointed out that the time was up, and suggested that the discussion could continue by
email or phone. But staff asked the panel to agree that, on the whole, with the small changes noted
above, the project can move forward. Panel members agreed.
Biomonitoring Updates
Members had no questions or comments.
Administrative Item
Because time was limited, Pat McGovern moved on to the next item: request for applications from panel
members whose terms end on December 31, 2013. Barbara Scott Murdock named those whose terms
would end on that date and handed out copies of the requirements for applications to the Office of the
Secretary of State (OSS). The OSS will post the open positions on the panel on November 4; applications
should be submitted by November 26, 2013.
Tracking Updates
Matthew Montesano gave a short presentation of new work on the data portal—Community
Environmental Health Profiles. This new web function will offer users an overview of environmental
health issues in their community (e.g., data by location for multiple indicators on the
state/grantee/national portals). It would allow users, such as local public health officials, to see all the
county-level data, compare the data to statewide averages, and use it for making graphs and tables.
Data users are now asking for community-level data, saying that county-level data are nice, but we need
more detailed community data, so MDH staff are beginning to develop a system for these data as well.
After giving a brief demonstration of examples, Matthew concluded by noting that the project is
underway and a little ahead of CDC.
Discussion
Bruce Alexander asked, are you able to export data broken out by other categories? Matthew replied
that people can integrate the data with other queries, carry out a more in-depth query, and crunch the
data by smaller categories.
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Adjournment
Pat McGovern adjourned the meeting. The next Advisory Panel meeting will be held on February 11,
2014, from 1:00–4:00 PM, at the American Lung Association.
63
Environmental Health Tracking & Biomonitoring Advisory Panel Roster
As of January 2014
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
840 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
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
64
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 & 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
[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
61
Biographical sketches of advisory panel members
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’s 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 a 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 and Dean of the College of Science and Engineering until June
2013. As Dean, he focused on providing up-to-date academic programming and facilities to serve the
needs of Minnesota employers in the health sciences, engineering, computing, biosciences, and STEM
education. He is currently a special advisor to the Provost for industrial collaboration and curriculum
alignment with workforce needs.
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 in the areas of 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.
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.
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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 degree in
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.
Gregory Pratt is a research scientist at the Minnesota Pollution Control Agency. He holds a Ph.D. in Plant
Physiology from the University of Minnesota, 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
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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.
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Staff Biosketches
Wendy Brunner, PhD, serves as surveillance epidemiologist for the MDH Asthma Program since 2002,
and joined Minnesota’s Environmental Public Health Tracking and Biomonitoring Program (MN
Tracking) program on a part-time basis in fall 2009. Previously, she worked on occupational respiratory
disease studies for MDH. She has a masters degree in Science and Technology Studies from Rensselaer
Polytechnic Institute and a masters degree in Environmental and Occupational Health from the
University of Minnesota. She received her doctorate in the Division of Epidemiology and Community
Health at the University of Minnesota.
Betsy Edhlund, PhD, is a research scientist in the Environmental Section of the Public Health Laboratory
at the Minnesota Department of Health. She works in the metals laboratory developing methods and
analyzing samples for both biomonitoring programs and emergency response. Betsy received her PhD in
chemistry from the University of Minnesota where her research focused on the photochemistry of
natural waters.
Jean Johnson, PhD, MS, is Program Director/Principal Investigator for MN Tracking. Dr. Johnson
received her Ph.D. and M.S. degrees from the University of Minnesota, School of Public Health in
Environmental Health and 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
University of Minnesota School of Public Health.
Tess Konen, 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 MN Tracking working
on birth defects, pesticides, climate change, and a follow-up study of the Northeast Minneapolis
Community Vermiculite Investigation cohort.
Mary Jeanne Levitt, MBC, is the communications coordinator with MN Tracking. She has a Masters in
Business Communications and has worked for over 20 years in both 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 Masters of Science degree in Biostatistics from the University of
Minnesota. She works for the Minnesota Department of Health as a biostatistician, and provides
statistical and technical support MN Tracking 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 Tracking, she works for various programs within Chronic Disease and
Environmental Epidemiology including the Asthma program, Center for Occupation Health and Safety,
Minnesota Cancer Surveillance System, and Cancer Control section.
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Jessica Nelson, PhD, is an epidemiologist with MN Tracking, 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.
Christina Rosebush, MPH, is an epidemiologist with MN Tracking. Her work includes the development
and coordination of biomonitoring projects that assess perfluorochemicals (PFCs) and mercury in
Minnesota communities. She also works on collection and statistical analysis of public health
surveillance data for MN Tracking, with a focus on behavioral risk factors. Christina received her Masters
degree in epidemiology from the University of Minnesota’s School of Public Health, completing research
in PFC biomonitoring for the Minnesota Department of Health in partial fulfillment of her degree.
Jeannette M. Sample, MPH, is an epidemiologist with MN Tracking at the Minnesota Department of
Health, working primarily with the collection and statistical analysis of public health surveillance data for
MN Tracking. She also works on research collaborations with academic partners relating to reproductive
outcomes and birth defects. Prior to joining MN Tracking, she was a CSTE/CDC Applied Epidemiology
Fellow with the MDH Birth Defect Information System. Jeannette received her Masters degree in
epidemiology and biostatistics from The George Washington University in Washington, DC.
Blair Sevcik, MPH, is an epidemiologist with MN Tracking at the Minnesota Department of Health,
where she works on the collection and statistical analysis of public health surveillance data for .MN
Tracking. Prior to joining MN Tracking in January 2009, she was a student worker with the MDH Asthma
Program. She received her Master of Public Health degree in epidemiology from University of Minnesota
School of Public Health in December 2010.
Chuck Stroebel, MSPH, is the MN Tracking 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 Masters 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 Minnesota EPHT Technical and Communications Teams.
Janis Taramelli, TTS, is the Community Outreach Coordinator for MN Tracking, responsible for
communications with the MN Tracking Advisory Panel and study participants. A tobacco treatment
specialist, she has 20 years of experience working on research studies, surveys, group facilitation, and
one-on-one counseling in both the public and private sectors. Her background includes development
and coordination of statewide QUITPLAN at Work programs, metro area QUITPLAN centers, and piloting
tobacco cessation and heart healthy programs for Minnesota’s Sage (Breast and Cervical Cancer
Screening) and SagePlus (Heart Health Screening) programs, funded by the Centers for Disease Control.
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
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supervisor for the MDH Center for Occupational Health and Safety. 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.
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Environmental Health Tracking and Biomonitoring Statute
$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, peerreviewed 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.
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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 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
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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
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(3) 100 voluntary participants from each of two communities that the commissioner identifies as
likely to have been exposed to perfluorinated chemicals, including 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;
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(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, communitybased 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
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(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;
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(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
(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: MN
Session Laws, Chapter 57
Current Appropriation for EHTB (see bolded text on page 75)
Office of the Revisor of Statutes
88th Legislature, 2013, Regular Session,
Chapter 114 Minnesota Session Laws
Subd. 2.Water
25,453,000
25,454,000
3,737,000
3,737,000
Appropriations by Fund
General
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State Government
Special Revenue
Environmental
75,000
75,000
21,641,000
21,642,000
$1,959,000 the first year and $1,959,000 the second year are for grants to delegated counties
to administer the county feedlot program under Minnesota Statutes, section 116.0711,
subdivisions 2 and 3. By January 15, 2016, the commissioner shall submit a report detailing the
results achieved with this appropriation to the chairs and ranking minority members at the
senate and house of representatives committees and divisions with jurisdiction over
environment and natural resources policy and finance. Money remaining after the first year is
available for the second year.
$740,000 the first year and $740,000 the second year are from the environmental fund to
address the need for continued increased activity in the areas of new technology review,
technical assistance for local governments, and enforcement under Minnesota Statutes,
sections 115.55 to 115.58, and to complete the requirements of Laws 2003, chapter 128, article
1, section 165.
$400,000 the first year and $400,000 the second year are for the clean water partnership
program. Any unexpended balance in the first year does not cancel but is available in the
second year. Priority shall be given to projects preventing impairments and degradation of
lakes, rivers, streams, and groundwater according to Minnesota Statutes, section 114D.20,
subdivision 2, clause (4).
$664,000 the first year and $664,000 the second year are from the environmental fund for
subsurface sewage treatment system (SSTS) program administration and community technical
assistance and education, including grants and technical assistance to communities for water
quality protection. Of this amount, $129,000 each year is for assistance to counties through
grants for SSTS program administration.
A county receiving a grant from this appropriation shall submit the resultsachieved with the
grant to the commissioner as part of its annual SSTS report. Any unexpended balance in the
first year does not cancel but is available in the second year.$105,000 the first year and
$105,000 the second year are from the environmental fund for registration of wastewater
laboratories.
$913,000 the first year and $913,000 the second year are from the environmental fund to
continue perfluorochemical biomonitoring in eastern metropolitan communities, as
recommended by the Environmental Health Tracking and Biomonitoring Advisory Panel, and
address other environmental health risks, including air quality. Of this amount, $812,000 the
first year and $812,000 the second year are for transfer to the Department of Health.
Notwithstanding Minnesota Statutes, section 16A.28, the appropriations encumbered on or
before June 30, 2015, as grants or contracts for SSTS's, surface water and groundwater
assessments, total maximum daily loads, storm water, and water quality protection in this
subdivision are available until June 30, 2018.
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