JOURNAL of Fifteen Dollars Environmentaldedicated to the Advancement of the Environmental Health Professional Healthvolume 80, No

Home , Asbestos Man

JOURNAL OF fifteen dollars EnvironmentalDedicated to the advancement of the environmental health professional HealthVolume 80, No. 1 July/August 2017

Published by the National Environmental Health Association www.neha.org

JEH7-8.17_PRINT.indd 1 6/15/17 3:28 PM Is this your current method of data collection?

For easier and more efficient inspections Call SWEEPS Today!

“Make Your Data Work As Hard As You Do!”

Software for Environmental and Consumer Health Agencies

JEH7-8.17_PRINT.indd 2 6/15/17 3:28 PM JOURNAL OF Is this your current method of data collection?

EnvironmentalDedicated to the advancement of the environmental health professional HealthVolume 80, No. 1 July/August 2017

ABOUT THE COVER ADVANCEMENT OF THE SCIENCE Outbreak Caused by Clostridium perfringens Infection and Intoxication Approximately at a County Correctional Facility ...... 8 11% of foodborne Gastroenteritis Associated With Rafting the Middle Fork of the Salmon River— outbreaks caused Idaho, 2013 ...... 14 by Clostridium perfringens occur Incidence of Non-Hodgkin Lymphoma and Residential Proximity to in correctional Superfund Sites in Kentucky ...... 22 facilities. This month’s cover ADVANCEMENT OF THE PRACTICE article investigates Special Report: Beneﬁts of a Study Abroad Element in the Environmental Health Curriculum ...... 30 an outbreak caused by C. perfringens infection and intoxication at a county correctional facil- Direct From AAS: Cross-Training: It’s Not Just for Athletes! ...... 34 ity. Based on estimates and projection calcula- Direct From CDC/EHSB: Understanding the Needs, Challenges, Opportunities, Vision, tions, the outbreak sickened 250–666 inmates. and Emerging Roles in Environmental Health ...... 36 While four different food items—chicken taco meat mixture, cheese sauce, rice, and beans— tested positive for C. perfringens enterotoxin, ADVANCEMENT OF THE PRACTITIONER outbreak investigation ﬁndings point to the EH Calendar ...... 38 chicken taco meat mixture as the culprit. Career Opportunities ...... 39 See page 8. Cover photos © iStock.com/Bonilla1879 and pamela_d_ Resource Corner ...... 40 mcadams For easier and more efficient inspections JEH Quiz #1 ...... 41 JEH Corresponding Author and Subject Index: Volume 79 ...... 42 Call SWEEPS Today! ADVERTISERS INDEX YOUR ASSOCIATION HealthSpace USA Inc ...... 56 President’s Message: All Generations Need Apply ...... 6 “Make Your Data Work As Hard As You Do!” Inspect2GO Environmental Health Software ...... 55 NEHA 2018 AEC ...... 46 Ozark River/Integrity Distribution ...... 39 NEHA Organizational Members ...... 47 QuanTem Laboratories ...... 21 Special Listing ...... 48 ® Sweeps Software, Inc...... 2 Tribute to 2016–2017 JEH Peer Reviewers ...... 50 NEHA News ...... 52 DirecTalk: Musings From the 10th Floor: Professional (dis) Association ...... 54

E-JOURNAL BONUS ARTICLE Software for Environmental and Consumer Health Agencies International Perspectives: Characteristics of Airborne Asbestos Concentrations in Korean Preschools ...... E1

July/August 2017 • Journal of Environmental Health 3

JEH7-8.17_PRINT.indd 3 6/15/17 3:28 PM Showcase Environmental Health and All It Encompasses

For many years NEHA’s Journal of Environmental Health has 24x36˝ been adorned by visually stunning and creative covers portraying a wide variety of environmental health topics. You 3 can now own these amazing cover images in poster size. Use the walls of your department and office to display to visitors, 18x24˝ • Three different sizes your boss and staff, and the public what environmental health • Laminated, high-quality prints encompasses and your pride in your profession. 2 • Select covers from 2005 to the present

For more information and to place your order: 8.5x11˝ ª Go to neha.org/publications/journal-environmental-health ª Contact us at [email protected] 1

Published monthly (except bimonthly in January/February and July/ Official Publication August) by the National Environmental Health Association, 720 S. Colorado Blvd., Suite 1000-N, Denver, CO 80246-1926. Phone: (303) 756- 9090; Fax: (303) 691-9490; Internet: www.neha.org. E-mail: kruby@ neha.org. Volume 80, Number 1. Yearly subscription rates in U.S.: $150 (electronic), $160 (print), and $185 (electronic and print). Yearly international subscription rates: $150 (electronic), $200 (print), and $225 (electronic and don’t print). Single copies: $15, if available. Reprint and advertising rates available at www.neha.org/JEH. CPM Sales Agreement Number 40045946. Claims must be fi led within 30 days domestic, 90 days foreign, Journal of Environmental Health © Copyright 2017, National Environmental Health Association (ISSN 0022-0892) (no refunds). All rights reserved. Contents may be reproduced only missin the next Journal with permission of the managing editor. of Environmental Health Opinions and conclusions expressed in articles, reviews, and other contributions are those of the authors only and do not refl ect the policies Kristen Ruby-Cisneros, Managing Editor or views of NEHA. NEHA and the Journal of Environmental Health are not Ellen Kuwana, MS, Copy Editor liable or responsible for the accuracy of, or actions taken on the basis of, any information stated herein.  Hotel Key Cards: How Clean Is Hughes design|communications, Design/Production the First Thing Guests Touch? NEHA and the Journal of Environmental Health reserve the right to reject Cognition Studio, Cover Artwork any advertising copy. Advertisers and their agencies will assume liability for  How Undertesting of Ethnic Soni Fink, Advertising the content of all advertisements printed and also assume responsibility for Meat Might Contribute to For advertising call 303.756.9090, ext. 314 any claims arising therefrom against the publisher. Full text of this journal is available from ProQuest Information and Antibiotic Environmental Pollution Learning, (800) 521-0600, ext. 3781; (734) 973-7007; or www.proquest. and Resistance com. The Journal of Environmental Health is indexed by Current Awareness Technical Editors in Biological Sciences, EBSCO, and Applied Science & Technology Index.  Response, Recovery, and It is abstracted by Wilson Applied Science & Technology Abstracts and Resilience to Oil Spills and William A. Adler, MPH, RS EMBASE/Excerpta Medica. Retired (Minnesota Department of Health), Rochester, MN Environmental Disasters All technical manuscripts submitted for publication are subject to peer Gary Erbeck, MPH review. Contact the managing editor for Instructions for Authors, or visit  Zika Virus in the Americas: Retired (County of San Diego Department www.neha.org/JEH. Is It Time to Revisit Mosquito of Environmental Health), San Diego, CA To submit a manuscript, visit http://jeh.msubmit.net. Direct all questions to Kristen Ruby-Cisneros, managing editor, [email protected]. Elimination Carolyn Hester Harvey, PhD, CIH, RS, DAAS, CHMM Periodicals postage paid at Denver, Colorado, and additional Eastern Kentucky University, Richmond, KY  E-Journal Article: Assessment mailing offi ces. POSTMASTER: Send address changes to Journal of of Food Operator Training on Thomas H. Hatfi eld, DrPH, REHS, DAAS Environmental Health, 720 S. Colorado Blvd., Suite 1000-N, Denver, CO 80246-1926. Parasitological Risk Management California State University, Northridge, CA Dhitinut Ratnapradipa, PhD, MCHES in Sushi Restaurants Printed on recycled paper. Sam Huston State University, Huntsville, TX

4 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 4 6/15/17 3:28 PM Updated and Redesigned to Meet the Needs of Today’s Learner NEHA PROFESSIONAL FOOD MANAGER 5th Edition

INSIDE THIS EDITION

Instructional design focused on improved learning and retention

Content aligns with American Culinary Federation Education Foundation competencies

Prepares candidates for CFP-approved food manager exams (e.g., Prometric, National Registry, ServSafe, etc.)

All-new instructor guide and companion classroom materials

Volume discounts for NEHA Food Safety Instructors

To order books or ﬁnd out more about becoming a NEHA Food Safety Instructor, call (303) 802-2166 or visit neha.org

July/August 2017 • Journal of Environmental Health 5

JEH7-8.17_PRINT.indd 5 6/15/17 3:28 PM YOUR ASSOCIATION

 PRESIDENT’S MESSAGE

All Generations Need Apply

Adam London, MPA, RS, DAAS

am very honored to serve you as NEHA’s that I earned delivering newspapers on my president during this coming year. I bicycle. I watched families like the Cunning- I think you will fi nd that I am going to be I believe in the hams, Waltons, Cosbys, and Keatons. None a very different sort of president than my pre- of them looked much like my family with decessors. To be clear, we have been blessed value of diversity— divorced parents, stepparents, and half sib- with a series of incredible presidents over the the variety of lings. I listened to hair metal bands followed past handful of years. I have had the privilege by grunge music during my college years at of serving with these tremendous men and generations that is Ferris State University in my beloved home- women on the NEHA board of directors since town of Big Rapids, Michigan. I saw Halley’s 2010. They have taught me a great deal and currently working Comet and wondered if I would live long I pray that I can carry their legacy forward. enough to see it again. As a matter of fact, Their work, and sometimes it was painfully in our profession I still wonder about that! I will never forget diffi cult work, has led our association to a provides us with watching the space shuttle Challenger disas- place of unprecedented strength and infl u- ter on television in Mr. Seaver’s fi fth grade ence. I am grateful for their leadership and I great strength. classroom. My environmental health sensitiv- hope I can match their enthusiastic embrace ities were formed as a child, in part, by ozone of our beloved association, but I want you to holes, the Exxon Valdez, and the Chernobyl nuclear reactor meltdown. If some of these know that I am going to be very different sort careers and young families can be involved things resonate with you, I am calling on you of president. with NEHA’s leadership. to get more involved—it’s time! Many of my predecessors were either I believe in the value of diversity—the In addition to having a full-time job as the retired or in the third act of their professional variety of generations that is currently work- health offi cer of a local health department in careers. These situations were a blessing to ing in our profession provides us with great Michigan, I am also married with six wonder- our association in many ways because they strength. Generational perspectives inform ful children. Our children range in age from were empowered to give generous amounts how we see the world and the values that we seven to 20 years. I suspect that you will be of time to NEHA’s business. They were also hold dear. Our association needs to refl ect hearing about at least of few of them in the able to personally travel to an astounding this truth and engage all generations in the stories that I will tell in upcoming columns or number of meetings and events. Their service work of leading us forward. NEHA will not during conferences. I believe that it is impor- and travel was important for the growth of reach its potential without all of you, regard- tant for busy people with families and full- the association during those periods of time. less of generation, being actively engaged in time employment to be willing and able to I believe, however, that the leadership of our the collective work of professional develop- lead NEHA. An association that can only be association should not be limited exclusively ment and advancing our causes. led by one certain type of person is probably to individuals from one generation or at one I was born in the 1970s and grew up in the an unhealthy association. stage of professional life. I will do my very 1980s and 1990s, making me the fi rst NEHA A few years ago, when I decided to run for best to follow in their footsteps and to repre- president to represent Generation X. The fi rst NEHA president, I told the attendees of our sent the association in as many places as pos- movie I can remember seeing at the theater Annual Educational Conference (AEC) & sible. To this end, I will use technology and was E.T. the Extra-Terrestrial. Arcade video Exhibition a true story about two young boys other tools to demonstrate that people with games consumed far too many of the quarters I encountered while collecting water samples

6 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 6 6/15/17 3:28 PM YOUR ASSOCIATION

at a Lake Michigan beach. Those little boys strive to provide you with the tools and sup- Grand Rapids! The conference site is in one exclaimed, “Mom, he’s like a superhero who port you need to grow as a professional and to of the most walkable downtowns in the U.S. protects us from germs!” As silly as that might serve your community. As a NEHA member, There are scores of museums, microbrew- sound, those boys understood something you belong to a club of extraordinary people eries, music venues, theaters, restaurants, that we often struggle to communicate—our and more important, you belong to a cause and more within an easy walk from the host true cause and calling. I believe that you truly that is changing the world for the better. hotel. I look forward to seeing you in Grand are superheroes called to protect your com- Lastly, I hope to see you in Grand Rap- Rapids and working with you during my munities from preventable illnesses and inju- ids for NEHA’s 81st AEC taking place July presidency. ries. Environmental health is a noble profes- 10–13. You may have heard that this city has sion and you truly are heroic. As we all know, made lots of top 10 lists for best places to however, all superheroes have weaknesses visit. I have lived in Grand Rapids for the and they all need allies and supporters. My past 16 years and based upon my personal promise to you is that this association will experience, you will have a great time in [email protected]

he NEHA Endowment Foundation was established to enable NEHA to do more for the environmental T health profession than its annual budget might allow. Special projects and programs supported by SUPPORT the foundation will be carried out for the sole purpose of advancing the profession and its practitioners. THE NEHA Individuals who have contributed to the foundation are listed below by club category. These listings are based on what people have actually donated to the foundation—not what they have pledged. ENDOWMENT Names will be published under the appropriate category for one year; additional contributions will move individuals to a different category in the following year(s). For each of the categories, there are FOUNDATION a number of ways NEHA recognizes and thanks contributors to the foundation. If you are interested in contributing to the Endowment Foundation, please call NEHA at 303.756.9090. You can also donate online at www.neha.org/donate. Thank you.

DELEGATE CLUB ($25–$99) 21st CENTURY CLUB David T. Dyjack, DrPH, CIH Name in the Journal for one year and endowment pin. ($500–$999) Denver, CO Name submitted in drawing for a free one-year Freda W. Bredy George A. Morris, RS NEHA membership, name in the Journal for one year, Alexandria, VA Dousman, WI and endowment pin.

HONORARY MEMBERS CLUB Peter M. Schmitt AFFILIATES CLUB ($100–$499) Shakopee, MN ($2,500–$4,999) Name submitted in drawing for a free AEC Letter from the NEHA president, name in the LCDR James Speckhart, MS registration, name in the Journal for one year, Journal for one year, and endowment pin. Silver Spring, MD and endowment pin. Tim Hatch, MPA, REHS Leon Vinci, DHA, RS Vince Radke, MPH, REHS, CP-FS, DAAS, CPH Montgomery, AL Roanoke, VA Atlanta, GA Lynne Madison, RS Hancock, MI SUSTAINING MEMBERS CLUB EXECUTIVE CLUB AND ABOVE ($1,000–$2,499) Paschal Nwako, MPH, PhD, REHS, CHES, DAAS ($5,000–$100,000) Name submitted in drawing for a free two-year Blackwood, NJ Special invitation to the AEC President’s Reception, NEHA membership, name in the Journal for one name in the Journal for one year, and endowment pin. Larry Ramdin, REHS, CP-FS, HHS year, and endowment pin. Salem, MA James J. Balsamo, Jr., MS, MPH, MHA, RS, CP-FS Ned Therien, MPH Metairie, LA Olympia, WA Gavin F. Burdge Lemoyne, PA Bob Custard, REHS, CP-FS Lovettsville, VA

July/August 2017 • Journal of Environmental Health 7

JEH7-8.17_PRINT.indd 7 6/15/17 3:28 PM 1 ﬁ gure, 3 tables, 1 photo

ADVANCEMENT OF THE SCIENCE

Outbreak Caused by Clostridium perfringens Infection and Intoxication at a County Correctional Facility Adam E. London, MPA, RS, DAAS Julie A. Payne, MPH Brian Hartl, MPH Kent County Health Department

tion, KCHD organized to investigate the suspected outbreak. Abstract Outbreaks of foodborne illness caused by Clostridium perfringens are not usually the result of intoxication and testing of suspected Methods menu items for colony count can often identify the causative item. We Following the report of illnesses on April 16, 2012, KCHD created investigation objec- describe a large outbreak at a county correctional facility in which the data tives to investigate the suspected outbreak by suggest that illness by intoxication contributed substantially to the outbreak: gathering appropriate epidemiological and 29 out of 108 surveyed cases (26.9%) developed symptoms within 2.5 hr of environmental data. The team gathering epi- when meal service began. Inmate testimony further suggests advanced food demiological data consisted of epidemiologists, public health nurses, and sanitarians. decay. Bacterial analyses of food samples indicated a smaller population of C. They developed a questionnaire using the perfringens in the chicken taco meat mixture (<10 CFU/g, enterotoxin positive) KCCF menu for the 72 hr prior to the onset compared with other items. Statistical analyses of food history data provided of the fi rst report of illnesses. Personal interviews were requested with substantially more support for the chicken taco meat mixture as causative inmates due to reported low literacy rates (odds ratio = 55.79, 95% confi dence interval [19.72, 157.83], p < .001) than within that population. KCHD staff con- other menu items. Environmental investigation and testimony from inmates ducted those interviews at the correctional provided additional support implicating the chicken taco meat mixture. facility on April 17–19. A total of 185 inmates, including ill and well individuals, were interviewed. Questions included: sex, age, food consumed, symptoms experienced, Introduction known to be ill at that time. The caller indi- date and onset of those symptoms, duration On April 16, 2012, at 8:30 a.m., the Com- cated that the lunch meal from the prior day of illness, and whether medical care was municable Disease/Epidemiology Unit of the was suspected to be the cause because many obtained. The case defi nition was described Kent County Health Department (KCHD) of the inmates complained about a foul taste as any interviewee reporting vomiting and/ in Grand Rapids, Michigan, received a tele- and odor associated with it. That meal was or diarrhea. Data analyses were performed phone call from an employee of the Kent served to inmates between 10:30 a.m. and using the Epi Info 6 Database Analysis Pro- County Correctional Facility (KCCF). The 12:30 p.m. on April 15 and consisted of a gram from the Centers for Disease Control KCCF employee reported that a foodborne chicken taco meat mixture, rice with cheese and Prevention (CDC). This team also iden- illness outbreak was suspected to be taking sauce, refried beans, and a fl our tortilla. A tifi ed ill inmates who were willing to pro- place at the facility. The caller stated that garden salad with optional salad dress- vide stool samples for laboratory analyses. approximately 30–50 inmates had become ing, yellow cake, and powdered fruit drink Those samples were collected and submitted ill with vomiting and diarrhea after eat- were also offered. According to the caller, to the Michigan Department of Community ing lunch at the facility on April 15, 2012. many people become ill within one hr after Health laboratory for both bacterial analyses The estimate of inmates who were ill later consuming the meal. Other inmates, how- and enterotoxin identifi cation through poly- increased to 250 out of 1,140 inmates as ever, developed symptoms throughout the merase chain reaction (PCR). more information became available. No remainder of that day and into the morning A second work team was charged with employees of the correctional facility were of April 16. Upon receipt of this informa- gathering environmental data from the

8 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 8 6/15/17 3:28 PM ADVANCEMENT OF THE SCIENCE

the outbreak was representative of the overall KCCF population (Table 1). TABLE 1 Onset of symptoms ranged from April 15 Profile of Surveyed Ill Respondents at 11:00 a.m. to April 18 at 8:00 p.m. The period of duration between exposure to the Characteristics # % suspect meal and onset of illness ranged from <1 hr to 81 hr, with a mean onset of 9 hr and a Gender median onset of 7 hr. The greatest frequency Female 24 22.22 of illnesses occurred within 1 hr after eating Male 84 77.78 the lunch meal on April 15. As illustrated by the epidemic curve (Figure 1), 29 of the 108 Total 108 ill interviewees (26.9%) reported an onset of Age (year) illness within 2.5 hr of when the lunch ser- 10–19 17 15.74 vice began. No employees of KCCF or of the 20–49 79 73.15 contracted food service company reported illness and none reported consuming the lunch 50–74 9 8.33 meal on April 15. Missing information 3 2.78 Data analyses (Epi Info 6) were utilized Total 108 to evaluate the 60 food items consumed by the KCCF population during the previous 72 hr according to the menu. Odd ratios (OR) Symptoms* # % Respondents and 95% confidence intervals (CI) were cal- Nausea 68 67.3 101 culated and p < .05 was used as a standard for significance. Interviewees were asked to Vomiting 39 38.6 101 indicate if they had consumed each of these Abdominal cramps 96 89.7 107 60 items. ORs for illness related to each of the Diarrhea 94 88.7 106 food items consumed before April 15 were insignificant. Food items consumed on April Bloody diarrhea 14 16.3 86 15 demonstrated statistically significant ORs Fever 24 29.3 85 indicating powerful likelihood of relationship (Table 2). The chicken taco meat mix- *Onset: range = <1–81 hr, mean = 9.3 hr, and median = 7 hr. Duration: range = 1–60 hr, mean = 19.13 hr, median = 17 hr. ture demonstrated a substantially greater OR than all other menu items: OR = 55.79, 95% CI (19.72, 157.83), p < .001. KCCF. This team, consisting primarily of teration had occurred. The sheriff’s depart- During the course of the interviews, sanitarians, assessed the food preparation ment and KCHD worked collaboratively to KCHD identified a subgroup of work release and service areas, investigated the history share valuable information essential to each employees with a unique experience. This of the suspect meals, questioned employ- department’s respective investigation. subgroup was presented with the same lunch ees for relevant information, and gathered on April 15 as other inmates, but they had food samples as appropriate. Correctional Results heard from other inmates that there was facilities are not licensed public food ser- something wrong with the chicken taco meat vice operations in the State of Michigan; Epidemiological mixture. The offensive odor of this food item however, the KCHD sanitarians used the Of the 185 surveyed individuals who con- was a common comment from the interview- Michigan Food Law of 2000 (Public Act 92 sumed lunch on April 15, 2012, 108 of them ees. Of the 42 work release employees, only of 2000), the 2005 Food and Drug Admin- were identified as ill according to the case 3 reported eating the chicken taco meat mix- istration (FDA) Food Code, and gener- definition. The survey results demonstrated ture and only 8 (19%) became ill. It should be ally accepted best food safety practices as an overall attack rate of 58.4%. It is, how- noted that the chicken taco meat mixture was guidance for conducting this investigative ever, important to acknowledge that it was often physically in contact with other food inspection. Food specimens were analyzed not possible to interview all inmates and that items on the serving tray. This contact might using PCR for enterotoxin source identifica- sickened inmates may have been more biased have transmitted infectious material and/or tion and incubated for plate count. toward participating in the survey than their enterotoxins from one food item to another It should be noted that the Kent County unaffected counterparts. The actual number in the pre-prepared serving tray. Sheriff’s Department also investigated the cir- of sick inmates likely ranged between 250 Stool specimens were collected from four cumstances associated with the outbreak to (KCCF estimate) and 666 (projection cal- ill inmate volunteers on April 16 and from determine if an act of intentional food adul- culated by survey attack rate). The profile of two additional inmate volunteers on April

July/August 2017 • Journal of Environmental Health 9

JEH7-8.17_PRINT.indd 9 6/15/17 3:28 PM ADVANCEMENT OF THE SCIENCE

FIGURE 1 Epidemic Curve

Meal served on April 14, 2012, demonstrates 10 contact of items in large serving section. Photo 8 courtesy of Kent County Health Department. Respondents 6 17. Based upon a recommendation by the Survey 4

Michigan Department of Community Health, Ill specimens were sent to their laboratory and 2 analyzed for Bacillus cereus and C. perfringens. All six specimens were found to be 0 0:00 1:00 2:00 3:00 4:00 5:00 6:00 7:00 8:00 9:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 negative for B. cereus and positive for C. per- 21:00 22:00 23:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 fringens. Conﬁrmatory PCR analyses detected April 15, 2012 April 16, 2012 the presence of C. perfringens enterotoxin in Date/Time of Illness Onset all six specimens.

Environmental Health period of time, and then covered in plastic sample meals from the dates in question. As The KCHD environmental health investiga- wrap and placed in the walk-in cooler. There a contractual requirement, they preserved tion team conducted an initial investigation was no indication that the temperature of these meals, popularly known as “dead man’s at the KCCF facility on April 16, 2012, and that chicken taco meat mixture was recorded trays,” in the cooler for several days in order made several follow-up visits during the sub- at that time or subsequently monitored until to support foodborne illness investigations. sequent two weeks. The team learned that Sunday, April 15 when the food was removed While no photographs of the suspected meal food service operations at KCCF were con- from the cooler and prepared for lunch service from April 15 were taken, KCHD investiga- tracted to a private company responsible for by reportedly reheating it to 200 °F (93.3 °C) tors did photograph a meal from the prior preparing meals, supervising kitchen trust- in steam kettles and then placing it in a hot day that demonstrates the general presenta- ees (inmates who are assigned to work in holding unit. A kitchen trustee stated that tion and appearance of meals served at KCCF. the kitchen under supervision), and ensur- the workers in the kitchen noticed that the It should also be noted that the meal items in ing food safety. Management staff from that hot holding unit did not appear to be work- the large section of the tray (beans and rice) company informed the KCHD environmental ing properly, so they transferred the chicken contacted one another in a similar way as was health team that the chicken taco meat mixed taco meat mixture to a pizza oven set at 150 reported from the April 15 meal (chicken taco with sauce was made from a pre-packaged fro- °F (65.6 °C) for hot holding. The kitchen meat mixture, rice with cheese, and beans). zen product. According to the kitchen man- trustee also reported that the chicken taco This sort of contact between meal items in ager, the meat was prepared on Friday, April meat mixture had “swelled and overflowed” the tray enables migration of microorganisms 13 by cooking it in steam kettles. Another and a strong odor was observed when the pans from one item to another. individual, a kitchen trustee, reported that were being transferred to the pizza oven. The Specimens of the chicken taco meat mix- the chicken taco meat mixture was heated on contracted kitchen manager later reported ture, beans, rice, cheese sauce, and tortillas Thursday, April 12, and that gravy leftovers that she checked the temperature of the pizza were sent to Michigan Department of Com- from an earlier meal were added into the oven and discovered that it was holding at 90 munity Health Bureau of Laboratories for chicken taco meat mixture. °F (32.2 °C). A number of others reported analyses. Cultured plate counts for C. per- While this trustee’s claim could not be con- that the chicken taco meat mixture had a very fringens found the rice and cheese mixture firmed, KCCF employees stated that it is not offensive odor and was “bubbly” and “frothy.” to contain 1.5 x 107 CFU/g, the beans con- unusual to combine leftovers into new meals The food processing and handling histories tained 3.7 x 105 CFU/g, and the chicken taco in order to conserve resources. The sources for the other meal items were investigated and meat mixture contained <10 CFU/g. Confir- agree that the chicken taco meat mixture was were found to comply with recipe directions matory analyses using PCR determined that brought to a simmer and then placed in large and without apparent abuse. the chicken taco meat mixture, rice with steel pans 4–6 in. deep, temporarily placed The contracted food service provider was cheese sauce, and beans all contained C. on a rack in the freezer for an undisclosed able to provide KCHD investigators with perfringens enterotoxin.

10 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 10 6/15/17 3:28 PM ADVANCEMENT OF THE SCIENCE

TABLE 2 Attack Rates for Foods of Signiﬁcance Consumed on April 15, 2012

Hot Cereal Breakfast Bakery Milk Chicken Cheese Flour Rice Refried Sausage Biscuit Taco Meat Sauce Tortilla Beans Mixture Ill Ate 68 66 64 74 100 102 103 101 89 Did not eat 33 16 22 26 5 6 5 7 18 Total 101 82 86 100 105 108 108 108 107 Illness rate (%) 67 80 74 74 95 94 95 94 83 Well Ate 32 34 36 31 19 48 53 52 42 Did not eat 40 56 50 41 53 25 19 21 32 Total 72 90 86 72 72 73 72 73 74 Wellness rate (%) 44 38 42 43 26 66 74 71 57

Respondents 145 172 172 172 177 181 180 181 181 OR 2.58 6.79 4.04 3.76 55.79 8.85 7.38 5.83 3.77 95% CI 1.4, 4.8 3.4, 13.6 2.1, 7.7 1.9, 7.2 19.7, 157.8 3.4, 23.0 2.6, 20.9 2.3, 14.6 1.9, 7.4 p-value .002 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001

OR = odds ratio; CI = conﬁdence interval.

The environmental health investigation Kent County Sheriff’s Department investiga- and abdominal cramping, which subsides in also identified a number of conditions non- tion was to determine if the food had been approximately 24 hr. Correctional facilities compliant with the 2005 FDA Food Code and criminally adulterated. Their interviews with and similar environments previously have best food safety practices. Monitoring and trustees did reveal information pertinent to been associated with these outbreaks (CDC, maintaining proper temperature controls in the KCHD investigation (presented in the 2009; CDC, 2012). an institution are essential for reducing the previous sections of this article), but did not Approximately 11% of foodborne out- risk of enteric outbreaks (Greig, Lee, & Har- find compelling evidence of criminal action. breaks caused by C. perfringens occur in cor- ris, 2011). In addition to significant time rectional facilities and 92% are related to meat and temperature control deficiencies, non- Discussion and poultry (Grass, Gould, & Mahon, 2013). compliant conditions included, but were not According to the FDA (2012) and the CDC Cases of intoxication are rare, in part because limited to faulty equipment, failure to date (2017a), C. perfringens is a spore-forming the food becomes very offensive to the senses mark food, inadequate sanitizing process for facultative bacterium located throughout the when this level of decay has occurred. Intoxi- dishware, poor utensil storage, inadequate environment but found primarily in the intes- cation is typified by a rapid onset of colic and hand washing sinks, evidence of pests, and tines of humans and many animals. The bac- diarrhea (Heymann, 2015). The presence of a number of minor maintenance issues. A teria are commonly found in raw meat prod- vomiting (38.6% of cases) in this outbreak is report consisting of 23 food safety improve- ucts. Small numbers of the organism often also suggestive of something unusual, such as ment recommendations was issued to KCCF are present after cooking and subsequently intoxication, considering that C. perfringens and the contracted food service company as a multiply to dangerous levels during improper usually only correlates with vomiting in 9% result of these findings. cooling and storage of prepared foods. Meats, of cases (Bennett, Walsh, & Gould, 2013). meat products, and gravy are the foods most Food and stool specimens confirmed that Criminal frequently associated with outbreaks caused the outbreak of gastroenteritis at KCCF Investigators from the Kent County Sheriff’s by C. perfringens. Illness generally is caused was caused by C. perfringens infection and/ Department interviewed 20 inmates who when sufficient numbers of the microbe are or intoxication. The epidemiological inves- had been assigned as trustees to work in the consumed and subsequently produce toxin in tigation in this case demonstrated that the kitchen under general supervision from the the intestines. The infection usually requires chicken taco meat mixture was the most contracted food manager. The purpose of the 8–12 hr to incubate before causing diarrhea statistically probable exposure causing the

July/August 2017 • Journal of Environmental Health 11

JEH7-8.17_PRINT.indd 11 6/15/17 3:28 PM ADVANCEMENT OF THE SCIENCE

TABLE 3 Evidence Summary for Foods of Signiﬁcance

Food Type Attack OR (95% CI) p-Value Clostridium Clostridium Environmental Comments Rate perfringens perfringens (%) (CFU/g) enterotoxin Hot cereal 67 2.58 (1.4, 4.8) .002 Breakfast sausage 80 6.79 (3.4, 13.6) <.001 Bakery biscuit 74 4.04 (2.1, 7.7) <.001 Milk 74 3.76 (1.9, 7.2) <.001 Chicken taco 95 55.79 (19.7, 157.8) <.001 <10 Positive Evidence of time/temperature abuse. Offensive odor meat mixture and “frothy” appearance reported. Served in contact with cheese, rice, and refried beans. Cheese sauce 94 8.85 (3.4, 23.0) <.001 1.5 x 107* Positive* Served in contact with chicken taco meat mixture, rice, and refried beans. Flour tortilla 95 7.38 (2.6, 20.9) <.001 Generally consumed with chicken taco meat mixture and other items. Unlikely C. perfringens media. Rice 94 5.82 (2.32, 14.6) <.001 1.5 x 107* Positive* Served in contact with chicken taco meat mixture, cheese sauce, and refried beans. Refried beans 83 3.77 (1.9, 7.4) <.001 3.7 x 105 Positive Served in contact with chicken taco meat mixture, cheese sauce, and rice.

OR = odds ratio; CI = conﬁdence interval. *Cheese sauce and rice were tested together due to extensive mixing in serving tray.

illnesses and the environmental investigation Vegetative spores of C. perfringens are ability of the chicken taco meat mixture was found significant abuse of this item. The lab- inactivated by cooking temperatures of 131 waning and the population of viable organ- oratory analyses, however, suggested that the °F (55 °C) for 16.3 min to 149 °F (65 °C) for isms could have decreased to <10 CFU/g rice with cheese and/or the beans were the 0.9 min (Byrne, Dunne, & Bolton, 2006). C. when the laboratory received the sample. The causative exposure (Table 3). CDC (2017b) perfringens enterotoxin is inactivated at 140 observations from inmates and staff regarding provides a confirmation guideline of 1 x 105 °F (60 °C) for five min (International Com- a strong foul smell and gas bubbles within the C. perfringens organisms/g in suspect food mission on Microbiological Specifications chicken taco meat mixture appear to support items, which supports the case for rice with for Foods, 2003). The unreliable reheating this second hypothesis. cheese and/or the beans. Due to the apparent in the faulty equipment on April 15 possibly conflict between the laboratory and statisti- could have inactivated vegetative spores, but Conclusion cal results, further consideration of the data not the enterotoxin, and left the remaining This outbreak of foodborne illness caused by was required. Two possibilities emerged for spores with greatly decayed growth media in C. perfringens exhibited the characteristics of the number of C. perfringens numbers in the the chicken taco meat mixture. As a result, an uncommon intoxication due to the short meat, rice with cheese, and beans. the chicken taco meat mixture environment onset of illness experienced by many of the One hypothesis suggested that—through contained C. perfringens enterotoxin but inmates who ate the food and the testimony either sampling error, laboratory error, or contained a nearly undetectable number of of foul odor and “bubbly” chicken taco meat uneven distribution of organisms—the viable organisms. Under this second hypoth- mixture. The occurrence of nausea (67.3%) chicken taco meat mixture sample that was esis, the high concentrations of C. perfrin- and vomiting (38.6%) may also suggest toxin analyzed for colony count was uniquely gens organisms in the cheese/rice mixture ingestion. Outbreaks caused by C. perfrin- underrepresented with viable C. perfringens and refried beans was caused by contami- gens intoxication may be uncommon, but organisms. The second hypothesis held that nation from the chicken taco meat mixture it is important to recognize that individuals the bacteria population within the chicken when the items contacted one another in the with limited control of their diet options may taco meat mixture had either reached death serving tray. be more vulnerable. The illnesses of other phase due to gross spoilage, diminishing The organisms would have found an accept- inmates were more likely caused by infec- nutrients, and a changing pH environment, able growth media in these newly exposed tion in the more frequently observed manner. or had been diminished by the final reheating items and could have multiplied substantially While the data appear to suggest conflicting prior to service on April 15 without harming by the time samples of those items were sub- causative food items, KCHD concluded that the integrity of the enterotoxin. mitted to the laboratory. Meanwhile, the suit- the chicken taco meat mixture was the most

12 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 12 6/15/17 3:28 PM ADVANCEMENT OF THE SCIENCE

probable cause. The high odds ratio, history foodborne illness outbreaks should recognize Corresponding Author: Adam London, Health of temperature abuse, possible contamina- the possible insuffi ciency of bacterial colony Offi cer, Kent County Health Department, 700 tion by external ingredients, and testimony counts from food samples for identifying the Fuller NE, Grand Rapids, MI 49503. from inmates regarding strong odor and causative menu item of a foodborne illness E-mail: [email protected]. frothy appearance seem consistent with C. outbreak. A full review of the environment, perfringens in the taco meat mixture. food history, statistical analyses, and popula- The fi ndings from this outbreak response tion dynamics should be considered before demonstrate that investigators of similar developing conclusions.

References Bennett, S.D., Walsh, K.A., & Gould, L.H. (2013). Foodborne dis- break. Retrieved from http://www.cdc.gov/foodsafety/outbreaks/ ease outbreaks caused by Bacillus cereus, Clostridium perfringens, investigating-outbreaks/confi rming_diagnosis.html and Staphylococcus aureus—United States, 1998–2008. Clinical Food and Drug Administration. (2012). Bad bug book: Handbook of Infectious Diseases, 57(3), 425–433. foodborne pathogenic microorganisms and natural toxins (2nd ed.). Byrne, B., Dunne, G., & Bolton, D.J. (2006). Thermal inactivation Silver Spring, MD: Author. Retrieved from https://www.fda.gov/ of Bacillus cereus and Clostridium perfringens vegetative cells and downloads/Food/FoodborneIllnessContaminants/UCM297627.pdf spores in pork luncheon roll. Food Microbiology, 23(8), 803–808. Grass, J.E., Gould, L.H., & Mahon, B.E. (2013). Epidemiology of Centers for Disease Control and Prevention. (2009). Clostridium foodborne disease outbreaks caused by Clostridium perfringens, perfringens infection among inmates at a county jail—Wiscon- United States, 1998–2010. Foodborne Pathogens and Disease, sin, August 2008. Morbidity and Mortality Weekly Report, 58(06), 10(2), 131–136. 138–141. Greig, J.D., Lee, M.B., & Harris, J.E. (2011). Review of enteric out- Centers for Disease Control and Prevention. (2012). Fatal food- breaks in prisons: Effective infection control interventions. Public borne Clostridium perfringens illness at a state psychiatric hos- Health, 125(4), 222–228. pital—Louisiana, 2010. Morbidity and Mortality Weekly Report, Heymann, D.L. (Ed.). (2015). Control of communicable diseases man- 61(32), 605–608. ual (20th ed.). Washington, DC: American Public Health Associa- Centers for Disease Control and Prevention. (2017a). Food safety: tion Press. Clostridium perfringens. Retrieved from http://www.cdc.gov/ International Commission on Microbiological Specifi cations for foodsafety/diseases/clostridium-perfringens.html Foods. (2003). Clostridium perfringens. Microorganisms in food: Centers for Disease Control and Prevention. (2017b). Foodborne Characteristics of microbial pathogens (1st ed., pp. 112–125). outbreaks: Guide to confi rming an etiology in foodborne disease out- United Kingdom: Kuwer Academic/Plenum.

Join the growing ranks of professionals who have attained NEHA’s most in- demand credentials in food safety. Whether your focus is retail foodservice CP-FS/CCFS or food manufacturing and processing, NEHA’s Certiﬁ ed Professional—Food Safety (CP-FS) and Certiﬁ ed in Comprehensive Food Safety (CCFS) credentials demonstrate you went the extra mile to get specialized knowledge and training in food safety. Give yourself the edge that is quickly being recognized, required, and rewarded in the food industry.

Learn more at neha.org/professional-development/credentials.

A credential today can improve all your tomorrows.

July/August 2017 • Journal of Environmental Health 13

JEH7-8.17_PRINT.indd 13 6/15/17 3:29 PM 1 ﬁgure, 3 tables

ADVANCEMENT OF THE SCIENCE

Mariana Rosenthal, MPH, PhD Gastroenteritis Associated With Epidemic Intelligence Service, Centers for Disease Rafting the Middle Fork of the Control and Prevention Idaho Department of Health and Welfare Salmon River—Idaho, 2013 Michael Taylor, MHE, CHES Kenneth S. Anderson, III, MSPH Eastern Idaho Public Health District Kris K. Carter, MPVM, DVM, DACVPM Centers for Disease Control and Prevention Idaho Department of Health and Welfare

USFS requires all boating parties to have rafting permits and carry specific equipment, During July–August 2013, a gastroenteritis outbreak Abstract including a portable toilet (USFS, 2015). occurred among rafters at Idaho’s Middle Fork of the Salmon River. To identify Private trips allow for dogs and group sizes the agent, source, and risk factors for illness, we solicited ill and well persons of 1–24 rafters. Commercial trips have a who rafted during July 1–September 23 to respond to an online survey, and maximum capacity of 30 persons, includ- conducted a case-control study. Cases were defined as nausea, vomiting, or ing professional guides. Meals, camping, and rafting gear; portable hand washing diarrhea 25 days after rafting; control subjects were rafters who did not ≤ stations (commonly referred to by product have these symptoms. Illness was associated with having consumed filtered name “Wishy Washy”); and toilet systems river water—70% (69/98) of case subjects and 38% (106/280) of control are provided by the outfitter. Twenty-seven subjects had consumed filtered water (odds ratio [OR] = 3.9; 95% confidence Middle Fork outfitters are licensed, but only interval [CI] [2.4, 6.4]). In a follow-up online survey of 33 case subjects and 3–4 outfitters may launch daily. Raft launch and takeout (exit) sites are at USFS camp- 73 control subjects, boiling water for drinking was protective against illness; grounds with flush and pit toilets, respec- 2/18 case subjects, compared with 15/33 control subjects, had boiled their tively. Approximately 90 primitive campsites, drinking water (OR = 0.2; 95% CI [0.03, 0.9]). From ill rafters, norovirus the majority accommodating groups of >20 (n = 3) and Giardia (n = 8) were detected in stool specimens. Norovirus was persons, are located along the river, which is dotted with hot springs. Primitive camp- detected on surfaces and E. coli in surface water used for drinking. Adherence ing, sometimes termed backcountry camp- to backcountry drinking water treatment recommendations is advised. ing, involves few or no amenities such as piped water, picnic tables, or pit toilets. No road access exists aside from the launch and Introduction Approximately 91 million adults in the U.S. takeout sites; private airstrips can be used for Outbreaks associated with recreational water recreate in natural bodies of water annually emergency evacuation. in the U.S. are detected and investigated by (Centers for Disease Control and Prevention, On July 24, 2013, emergency services per- state, local, and federal health agencies and 2016); during 2013, an estimated 3.8 million sonnel notified Eastern Idaho Public Health voluntarily reported to the Centers for Disease persons participated in rafting activities (Out- District (EIPHD) that five persons rafting Control and Prevention (CDC). During 1971– door Foundation, 2014). for work-related purposes were transported 2012, an estimated 48,528 cases of illness In the Frank Church River of No Return from a river takeout site by ambulance to a occurred in the U.S. as a result of outbreaks Wilderness in Central Idaho, the Middle Fork local hospital because of nausea, vomiting, associated with recreational water (Craun, of the Salmon River traverses northeast at a diarrhea, cramping, and dehydration. Upon Calderon, & Craun, 2005; Dziuban et al., mean discharge of 1,030 ft3 of water/second contacting the hospital’s infection control 2006; Hlavsa et al., 2011; Hlavsa et al., 2014; (measured in July–August 2013) through practitioner, EIPHD learned that the five ill Hlavsa et al., 2015; Yoder et al., 2004; Yoder rugged mountains (Northwest River Forecast workers were treated for viral gastroenteri- et al., 2008). Recreational water illnesses can Center, n.d.). Each year, approximately 10,000 tis, discharged, and no clinical specimens be caused by bacteria, viruses, protozoa, and rafters embark on nonmotorized, whitewater for laboratory testing were collected because fungi, and can be transmitted by ingestion or rafting trips along this 104-mile stretch of patients were unable to produce stool. The contact with contaminated water in treated river for an average of 4–10 days, in both pri- ill workers were provided motel rooms and (e.g., swimming pools or drinking fountains) vate and commercial trips (U.S. Department of time away from work until they were symp- and untreated (e.g., lakes or rivers) venues. Agriculture, Forest Service [USFS], 2017). tom-free. Because norovirus was the sus-

14 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 14 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

results, we reclassiﬁed cases by gastrointestinal illness duration: norovirus-like gastroen- FIGURE 1 teritis cases had an illness duration ≤3 days Dates of Illness Onset Reported by Rafters of the Middle Fork of the and Giardia-like gastroenteritis cases had an Salmon River—Idaho, 2013 (n = 95a) illness duration ≥4 days. 10 Case-Control Study

EIPHD Flooding and To identify risk factors for illness, EIPHD alerted mudslides; and DPH initiated a case-control study. 8 to reports USFS receives USFS of illness three-container Unmatched control subjects were well persons receives messagec outfitter who had rafted July 1–September 23. We cre- brochureb 6 Online ated an online questionnaire hosted by DPH survey August 7–October 22, and asked rafters to posted USFS posts In-person rafter brochuree respond only if they rafted the river on or after interviews 4 and survey link July 1, 2013. Information from the question- # of Rafters naire, which asked about symptoms, meals Food safety messaged consumed, drinking water, and environmen- 2 aired on tal exposures, helped us create deﬁnitions radio for cases and controls. To determine the total number of persons who went on rafting trips 0 with a launch date during July 1–September

2-Jul 4-Jul 6-Jul 8-Jul 23, 2013, DPH requested information under 1-Aug 3-Aug 5-Aug 7-Aug 9-Aug 10-Jul 12-Jul 14-Jul 16-Jul 18-Jul 20-Jul 22-Jul 24-Jul 26-Jul 28-Jul 30-Jul 11-Aug 13-Aug 15-Aug 17-Aug 19-Aug 21-Aug 23-Aug 25-Aug 27-Aug the Freedom of Information Act (FOIA) from Date of Illness Onset USFS regarding the number of permits issued. EIPHD = Eastern Idaho Public Health District; USFS = U.S. Forest Service. Information from USFS-issued rafting permits aIllness onset date was unavailable for seven case subjects. was used to determine whether group size or bPrevent Foodborne and Waterborne Illness: Recommendations for Idaho River Outfitters (www.healthandwelfare.idaho. permit holder type was a risk factor for illness. gov/Portals/0/Health/Epi/River%20Raft%20Brochure_FINAL_Updated_20130801.pdf). Excel 2010, EpiInfo 7, and SAS version 9.1.3 cThe three-container method is a technique used to clean and sanitize dishes when automatic dishwashing equipment were used for data analyses. Univariate analy- is unavailable. See A Quick Reference for River Rafters: Cleaning and Sanitizing Dishes Using the Three-Container Method (www.healthandwelfare.idaho.gov/Portals/0/Health/FoodProtection/CleaningDishes.pdf). ses were performed to determine statistical dA Closer Look at Your Health: Food Handling on a River Trip transcript of podcast available at www.healthandwelfare. significance of an association between illness idaho.gov/Portals/0/Health/FoodProtection/0813_RiverFoodTips.pdf. and exposures (α = .05). eRunning the River (Without Getting the Runs): How to Prevent and Control Vomiting and Diarrheal Illness on River Rafting Trips (www.healthandwelfare.idaho.gov/Portals/0/Health/Epi/Waterborne/RiverRaftingSafetyWeb_FINAL.pdf). Clinical Investigation During the investigation, EIPHD provided stool sample kits to USFS, clinics, and hospital pected cause of illness, a cleaning crew was rhea ≤25 days after rafting (maximum incu- emergency departments to be used for speci- hired to disinfect the motel rooms after they bation period for giardiasis) in a person who men submission to the Idaho Bureau of Labo- were vacated; the rafting equipment used on had rafted July 1–September 23, 2013. To ratories (IBL) from patients who presented the work-related rafting trip was also disin- find persons who had rafted the Middle Fork with symptoms of gastrointestinal illness after fected. During July 24–August 6, 2013, until of the Salmon River during July 1–September rafting the Middle Fork of the Salmon River a mudslide from heavy rains disrupted com- 23, 2013, EIPHD and the Idaho Department of during July 1–September 23, 2013. EIPHD munications, EIPHD received qualitative Health and Welfare, Division of Public Health also provided stool sample kits to USFS to col- reports from USFS regarding gastrointestinal (DPH) solicited participants to respond to an lect stool samples from ill rafters who did not illness among rafters. To determine the agent, online questionnaire through the media (e.g., seek care. At IBL, stool samples were tested source, and risk factors for gastrointestinal 670 KBOI radio, local newspapers, and televi- by culture for Salmonella, Shigella, Shiga- illness among rafters of the Middle Fork of sion), in person (i.e., at the Cache Bar river toxin producing E. coli, and Campylobacter; the Salmon River during July 1–September takeout on August 11, 2013), and by USFS by direct fluorescent antibody (DFA) assay for 23, 2013, EIPHD began an investigation. sending e-mails to rafting permit holders to Cryptosporidium and Giardia; and by reverse- distribute to trip participants. To find addi- transcription polymerase chain reaction (RT- Methods tional ill patients, EIPHD requested that clin- PCR) assay for norovirus. ics and hospital emergency departments con- Identification of Cases tact EIPHD regarding patients who presented Environmental Investigation The cause of illness was unknown; therefore, with gastroenteritis symptoms after rafting To collect environmental samples at loca- we defined a case as nausea, vomiting, or diar- the Middle Fork. After receipt of laboratory tions along the river, IBL provided supplies to

July/August 2017 • Journal of Environmental Health 15

JEH7-8.17_PRINT.indd 15 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

TABLE 1 Potential Risk Factors for Gastrointestinal Illness Among Rafters, Middle Fork of the Salmon River (N = 395: 102 Case Subjects and 293 Control Subjects)—Idaho, 2013

Risk Factor Case Subjects Control Subjects Difference OR 95% CI in % Exposed Exposed Unexposed Exposed Unexposed #a # (%) # (%) # (%) # (%) Ate at area restaurant pretrip 391 52 (51) 50 (49) 140 (48) 149 (52) 3 1.1 0.7, 1.7 Commercial (nonprivate) trip 395 24 (24) 78 (76) 64 (22) 229 (78) 1 1.1 0.6, 1.9 Prepared own meals during trip 391 77 (76) 25 (24) 230 (80) 59 (20) 5 0.8 0.5, 1.4 Outfitter prepared meals during trip 391 29 (28) 73 (72) 64 (22) 225 (78) 6 1.4 0.8, 2.3 Location A (mile 0, river launch site) Used/touched spigot 382 50 (52) 47 (48) 149 (52) 136 (48) 1 1 0.6, 1.5 Used/touched toilet 389 59 (58) 42 (42) 184 (64) 104 (36) 6 0.8 0.5, 1.3 Location B (mile 25, airstrip) Used/touched spigot 381 35 (36) 62 (64) 120 (42) 164 (58) 6 0.8 0.5, 1.2 Used/touched toilet 389 36 (36) 65 (64) 105 (36) 183 (64) 0 1 0.6, 1.6 Location C (mile 67, airstrip) Used/touched spigot 380 31 (32) 66 (68) 89 (31) 194 (69) 1 1 0.6, 1.7 Used/touched toilet 389 24 (24) 77 (76) 77 (27) 211 (73) 3 0.9 0.5, 1.5 Ate at Location C 382 11 (11) 89 (89) 26 (9) 256 (91) 2 1.2 0.6, 2.6 Location D (mile 100, river exit site) Used/touched spigot 379 4 (4) 93 (96) 14 (5) 268 (95) 1 0.8 0.2, 2.7 Used/touched toilet 389 23 (23) 78 (77) 84 (29) 204 (71) 6 0.7 0.4, 1.2 Drank filtered creek water 363 31 (33) 62 (67) 73 (27) 197 (73) 6 1.4 0.8, 2.2 Drank filtered river water 378 69 (70) 29 (30) 106 (38) 174 (62) 32 3.9 2.4, 6.4 Drank unfiltered creek water 385 17 (17) 82 (83) 65 (23) 221 (77) 6 0.7 0.4, 1.3 Drank unfiltered river water 390 5 (5) 97 (95) 6 (2) 282 (98) 3 2.4 0.6, 9.7 Went into a natural hot spring 395 79 (78) 23 (22) 252 (86) 41 (14) 9 0.6 0.3, 1.0 Ate at area restaurant posttrip 395 64 (63) 38 (37) 185 (63) 108 (37) 0 1 0.6, 1.6

OR = odds ratio; CI = conﬁdence interval. aNumber of respondents to the online questionnaire.

USFS, EIPHD, and the Central District Health ples from hard surfaces. Water samples from nated educational materials, DPH admin- Department (CDHD). Samples were collected potable water spigots at Location A, from a tap istered a follow-up online questionnaire to during August–October 2013. Water samples and surface water source at Location C, and study participants who had agreed to answer for E. coli and coliform testing were collected from springs at Locations E and F were col- follow-up questions. and tested by using Standard Method 9223B lected and tested by DFA and RT-PCR for one (National Environment Methods Index, n.d.). or more of the following: E. coli, total coliform Results To collect water, without additives, for norovi- bacteria, Giardia cysts, Cryptosporidium oo- rus and Giardia testing, 20 L collapsible con- cysts, and norovirus. Participant Characteristics tainers were used. These were stored at 4° C A total of 490 persons responded to the until concentrated by ultraﬁltration, at which Follow-Up Study online questionnaire. The response to the point sodium polyphosphate (surfactant aid) During March 5–April 5, 2014, to obtain FOIA request for information from the USFS was added (Hill et al., 2007). Sterile, dry swabs additional information on drinking water showed that during July–August 2013, a total were used for collecting environmental sam- treatment methods, sanitation, and dissemi- of 7,399 persons rafted the Middle Fork of

16 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 16 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

TABLE 2 Laboratory Results From Environmental Samples Collected at Locations Along the Middle Fork of the Salmon River—Idaho, 2013

Sample Sample Collection Sample E. coli Total Giardia Cryptosporidium Norovirus Location Date Type Coliforms Cysts Oocysts (Genogroup) A Spigot 1 8/11/13 Water Absent Absent NT NT NT Spigot 2 8/11/13 Water Absent Absent NT NT NT Spigot 1 9/24/13 Surface swab NT NT NT NT Positive (II) 9/24/13 Water NT NT Negative Negative Negative Spigot 2 9/24/13 Surface swab NT NT NT NT Positive (II) C Surface water 10/1/13 Water 13.4 MPN/100 mL 652.3 MPN/100 mL Negative Negative Negative source 10/21/13 Water <1 MPN/100 mL 59.8 MPN/100 mL NT NT NT Water tap 10/1/13 Water 14.6 MPN/100 mL 488.4 MPN/100 mL Negative Negative Negative River (downstream) 10/1/13 Water NT NT Negative Negative Negative E Springs 9/30/13 Water NT NT Negative Negative Negative F Springs 10/1/13 Water NT NT Negative Negative Negative

NT = not tested; MPN = most probable number. Note: Locations are listed in order of river ﬂow from launch to exit. Springs refer to cold water springs from which rafters reported collecting water for drinking (two samples were taken from each spring and pooled before testing). Water samples were tested only for the presence of Giardia cysts and Cryptosporidium oocysts.

the Salmon River under USFS-issued raft- during, and after the trip; spigot or toilet I. Sequencing performed on one of the stool ing permits, indicating that 6.6% of possible use along the river; or rafting group size. In specimens detected norovirus genotype I_8. respondents answered the survey. Of these all, 69 (39.4%) of 175 rafters became ill after 490 persons, 91 (19%) were excluded from drinking filtered river water (odds ratio [OR] Environmental Investigation the study for not having rafted during July = 3.9; 95% confidence interval [CI] [2.4, Table 2 summarizes the laboratory test results 1–September 23. Moreover, four respondents 6.4]) (Table 1). The association between ill- of the environmental samples. Water samples were excluded for reporting influenza-like ness and drinking filtered river water was tested negative for Giardia cysts and Crypto- symptoms and no gastrointestinal symp- stronger among the 63 norovirus-like gastro- sporidium oocysts. E. coli and total coliforms toms. Of the resulting 395 respondents, 102 enteritis cases (OR = 6.6; 95% CI [3.3, 12.9]) were detected in samples from a tap and a (25.8%) met the case definition and 293 compared with the 38 Giardia-like gastroen- surface water source at Location C. Norovi- (74.2%) met the control definition and thus teritis cases (OR = 2.2; 95% CI [1.1, 4.3]). rus genogroup II was detected in swabs of were included in the unmatched case-control outhouse and spigot surfaces at Location A. study. Among case subjects, illness onset was Clinical Investigation throughout July and August (Figure 1). Study Among the 102 case-patients, 75 (73.5%) Follow-Up Study participants’ ages ranged from 10 to 85 years. had nausea; 51 (50%) had vomiting; and The male to female ratio and mean age did 80 (78.4%) had diarrhea. Median symptom Drinking Water Treatment Methods not differ significantly between case subjects duration was 2 days (range: 1–49 days). In During March 5–April 5, 2014, a total of (32 [31.4%] female; mean age = 45.5 years) all, 23 (22.5%) case subjects reported seek- 106 participants responded to the follow-up and control subjects (121 [41.3%] female; ing medical attention; of these, 13 (56.5%) questionnaire; of these, 33 (31.1%) were case mean age = 49.7 years) (p-value = .08 and reported having had clinical specimens sub- subjects and 73 (68.9%) control subjects. p-value = .06, respectively). Among the 102 mitted for laboratory testing. In questionnaire Sixteen (48.5%) case subjects and 37 (50.7%) cases, 1 was missing symptom duration; 63 responses, three rafters who were non-Idaho control subjects reported treating drinking (62%) met the norovirus-like gastroenteritis residents reported Giardia as their labora- water. Of these, six (37.5%) case subjects case definition; and 38 (38%) met the Giar- tory test result. Laboratory results received and 13 (35.1%) control subjects reported dia-like gastroenteritis case definition. on seven rafters who were Idaho residents that they did not allow for any sedimentation confirmed detection of Giardia in stool (n = before treating water for drinking, although Case-Control Study 4), norovirus in stool (n = 2), and vomitus (n they reported that little sediment was present No association was identified between illness = 1). Real-time PCR results from the vomi- in the water; 2 (12.5%) case subjects and 15 and exposure to hot springs; meals before, tus specimen detected norovirus genogroup (40.5%) control subjects boiled their drink-

July/August 2017 • Journal of Environmental Health 17

JEH7-8.17_PRINT.indd 17 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

TABLE 3 Potential Risk Factors for Gastrointestinal Illness Among Rafters Responding to Follow-Up Survey, Middle Fork of the Salmon River (N = 106: 33 Case Subjects and 73 Control Subjects)—Idaho, 2013

Risk Factor Case Subjects Control Subjects Difference OR 95% CI in % Exposed Exposed Unexposed Exposed Unexposed # # (%) # (%) # (%) # (%) Used river, creek, or spring water to rinse dishes/ 97 6 (19) 25 (81) 10 (15) 56 (85) 4 1.3 0.4, 4.1 utensils without soap Used spigot water to rinse dishes/utensils without soap 93 11 (38) 18 (62) 15 (23) 49 (77) 15 2 0.8, 5.1 Used river, creek, or spring water to brush teeth 102 3 (10) 28 (90) 9 (13) 62 (87) 3 0.7 0.2, 2.9 Used spigot water to brush teeth 101 10 (32) 21 (68) 18 (26) 52 (74) 6 1.4 0.5, 3.5 Drank water directly from river, creek, or spring 104 5 (16) 27 (84) 15 (21) 57 (79) 5 0.7 0.2, 2.1 Drank water directly from spigot 99 15 (50) 15 (50) 33 (48) 36 (52) 2 1.1 0.5, 2.6 Reported treating water for drinking 106 16 (48) 17 (52) 37 (51) 36 (49) 3 0.9 0.4, 2.1 By ﬁltering 53 16 (100) 0 (0) 26 (70) 11 (30) 30 – – By boiling 49 2 (13) 14 (87) 15 (45) 18 (55) 32 0.2 0.03, 0.9 By using chemicals 53 3 (19) 13 (81) 17 (46) 20 (54) 27 0.3 0.1, 1.1 By using ultraviolet (UV) penlight 53 0 (0) 16 (100) 4 (11) 33 (89) 11 – – Reported knowing how other(s) treated their water 53 6 (35) 11 (65) 12 (33) 24 (67) 2 1.1 0.3, 3.7 Other(s) ﬁltered their water ––––– ––– Other(s) boiled their water 18 2 (33) 4 (67) 0 (0) 12 (100) 33 – – Other(s) added chemicals to their water 18 3 (50) 3 (50) 3 (25) 9 (75) 25 3 0.4, 23.7 Other(s) used UV on their water ––––– ––– Hand sanitizer was always available 105 30 (91) 3 (9) 62 (86) 10 (14) 5 1.6 0.4, 6.3 Hand washing stations were always stocked 85 25 (93) 2 (7) 57 (98) 1 (2) 5 0.2 0.02, 2.5 Received or saw any health and safety educational 75 17 (71) 7 (29) 34 (67) 17 (33) 4 1.2 0.4, 3.5 materials

OR = odds ratio; CI = conﬁdence interval.

ing water (Table 3); all reported boiling ≥1 treatment to consume the water. No case sub- gent or sanitizer) to do a final rinse on their min. Boiling drinking water ≥1 min had a sta- jects or control subjects reported their water dishes and utensils, to brush their teeth, and tistically significant protective effect against being cloudy before treatment. Zero case sub- to drink. illness (OR = 0.2; 95% CI [0.03, 0.9]). All 16 jects and 4 control subjects used ultraviolet (100%) case subjects and 26 (70.3%) control (UV) light to treat their drinking water, and Backcountry Sanitation subjects had filtered their drinking water. all used it on ≤1 L of water, the maximum No statistically significant association existed Of these, only 3 (19%) case subjects and 3 volume recommended for purifying water between frequency of hand hygiene before (11.5%) control subjects knew the pore size with UV penlights by popular commercial handling water treatment equipment and ill- of their filters; 1 (6.3%) case-patient and 7 manufacturers (e.g., SteriPEN, CamelBak). ness. One rafter reported “most people think (26.9%) control subjects did not replace their Zero case subjects and 4 control subjects that the river water is clean and they do not filter cartridge because it looked clean. In reported doing a combination treatment: 1 wash with soap or use wipes before eating or all, 12 (75%) case subjects and 17 (65.4%) control subject filtered, then used chemicals; drinking.” Furthermore, 82 (77.4%) of 106 control subjects did not treat their water with and 3 control subjects filtered, then used rafters reported never running out of soap chemicals after filtering. UV light. Water from multiple spigots along and water in portable hand washing stations; Of the 20 respondents who treated their the river was used directly by case subjects however, 21 (19.8%) rafters reported never water with chemicals, all waited 1–5 min after and control subjects (without using a deter- having encountered such stations. Many raf-

18 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 18 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

ters, 92 (86.8%), reported having hand sani- cant risk factor for illness, detection of noro- Limitations of our study include selection tizer available throughout their trip. virus from swabs of spigot and outhouse sur- of a nonrandom sample of rafters to partici- faces supports the hypothesis that viral trans- pate in the case-control study. We had contact Educational Materials mission might still have occurred through information for permit holders, but not for all Guidelines for gastrointestinal illness preven- contact with these commonly touched con- persons who rafted the river; consequently, tion, including sanitation, food handling, and taminated surfaces. Norovirus can survive on we relied on the permit holders to further water treatment, were created and dissemi- surfaces and in water for weeks to months distribute the online questionnaire to their nated to rafters throughout the outbreak. (Boone & Gerba, 2007; Seitz et al., 2011). fellow rafters. Moreover, dissemination of the From the follow-up online survey, of 51 In this investigation, E. coli detected in questionnaire to the majority of rafters and (48.1%) rafters who reported that they were surface water used for drinking indicated the completion was dependent on the participant exposed to these health education materials, presence of fecal contamination, which can rafter having Internet access. Additionally, few 47 (92.2%) believed they were helpful. be a norovirus or Giardia source as well. Ab- reported illnesses were laboratory-confirmed; sence of E. coli detection in the surface water, therefore, other etiologic agents might have Discussion however, does not indicate that norovirus or been present but undetected. Our investigation of a gastroenteritis outbreak Giardia is not present (Harwood et al., 2005). Past the launch site, the Middle Fork of among rafters at Idaho’s Middle Fork of the Detection of Giardia cysts and two different the Salmon River is accessible only by raft- Salmon River during July–August 2013 indi- norovirus genogroups in this outbreak adds ing, hiking, pack animal, and chartered or cated no single cause or source. Both Giardia to the challenges in pinpointing a common private aircraft, highlighting the importance and norovirus were detected among ill rafters, source. A possible explanation for the differ- of disseminating public health messages be- and norovirus, E. coli, and total coliforms ent genogroups of norovirus detected might fore launching. Frequent disinfection of en- were detected from environmental samples. be that human stool samples were submitted vironmental surfaces with an approved disin- Factors that most likely contributed to the weeks before environmental samples were fectant for norovirus could prevent exposures spread of gastrointestinal illness included en- obtained, and that different norovirus strains from contaminated surfaces that are often vironmental contamination and consumption were introduced into the environment at dif- touched, including spigot handles, oars, rafts, of inadequately treated water. Gastroenteritis ferent times. life jackets, and human waste containers outbreaks have been reported among rafters of Drinking filtered water from Idaho’s Middle (e.g., unimproved metal ammunition boxes, the Colorado River (Jones, Gaither, Kramer, & Fork of the Salmon River during July–August known as “groovers”). Sodium hypochlorite Gerba, 2009; Malek et al., 2009) and for those 2013 was a statistically significant risk factor (chlorine bleach) or another product regis- where the etiologic agent was confirmed, were for illness. This association was stronger for tered by the U.S. Environmental Protection as a result of norovirus contamination. To our case subjects who had a shorter duration of Agency as being effective against norovirus is knowledge, our report is the first published illness (≤3 days), characteristic of norovirus recommended (U.S. Environmental Protec- account of a gastroenteritis outbreak among infection. Noroviruses have a particle size of tion Agency, 2017). Quaternary ammonium whitewater rafters in the U.S. with illness as- 27–38 nm, whereas a typical drinking water compounds are less effective and should not sociated with multiple etiologies. filter removes larger particles sized >0.1–0.2 be used for norovirus disinfection. Identifying an outbreak source in this type µm. To remove norovirus, a water filter would Familiarity with filter options (e.g., pore of setting is challenging. Public health offi- need to filter particles sized ≤0.027 µm. size, shelf life), as well as replacing and cials investigating a gastrointestinal illness If additional treatment to inactivate noro- cleaning filters according to manufacturer’s outbreak that occurred during a whitewater virus is not performed, as was the case in recommendations are strongly advised. In- rafting trip at the Zambezi River in Africa in our outbreak, this might explain why the creasing public awareness that natural bod- 2008 never identified a source, citing lack of association between drinking filtered water ies of water are not clean or pristine might knowledge of food consumed. Potential risk from the river was higher for illness of short- lead rafters to improve their backcountry factors listed were inadequate sanitation and er rather than longer duration. Giardia par- drinking water treatment methods. Despite hygiene, lack of safe food storage, unsafe ticles are larger (10–15 µm) than norovirus survey participants reporting not having water usage, inadequate toilet facilities, and and would not pass through typical water received or seen any disseminated public exposure to potentially contaminated river filters. Further analysis of rafters’ reported health educational materials, those who did water (Ntshoe et al., 2009). Three of the six water treatment practices confirmed that see materials reported that they were help- investigations of gastrointestinal illness out- filters were inadequate in making the back- ful. During June 2014, the Middle Fork breaks associated with rafting the Colorado country water safe for drinking when used Outfitters Association, with assistance from River during 1994–2005 could not identify without further treatment. We determined public health officials, created and dissemi- a source (Jones et al., 2009). Not identifying that the only effective surface water treat- nated a handout on norovirus infection pre- the outbreak source, a common limitation, ment method used was boiling, but only a vention to guides and clients. USFS installed hampers control and prevention, and dilutes small proportion of rafters had boiled their sanitizer dispensers and outfitter-donated public health prevention messages. drinking water. The majority of rafters fil- hand washing stations outside outhouses. Although our investigation did not find tered but did not chemically treat their wa- USFS briefings to rafters before launching spigot or toilet use to be a statistically signifi- ter after filtering. stressed that rafters should drink water only

July/August 2017 • Journal of Environmental Health 19

JEH7-8.17_PRINT.indd 19 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

from approved water systems or water that son, no gastroenteric disease outbreaks on Corresponding Author: Mariana Rosenthal, is filtered, highlighted that filters alone will the Middle Fork of the Salmon River were Center for Health Statistics, Division of Dis- not guarantee protection, reminded rafters reported. ease Control and Health Statistics, Washing- about hand washing after using waste con- ton State Department of Health, 101 Israel tainment systems, and recommended that Disclaimer: The findings and conclusions in Road SE, Tumwater, WA 98501. rafters try not to vomit in the river but in- this article are those of the author(s) and do E-mail: [email protected]. stead on vegetated land if they got sick dur- not necessarily represent the official position ing their trip. During the 2014 rafting sea- of CDC.

References Boone, S.A., & Gerba, C.P. (2007). Significance of fomites in the Errata in Morbidity and Mortality Weekly Report, 63(04), 82. spread of respiratory and enteric viral disease. Applied and Envi- Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/ ronmental Microbiology, 73(6), 1687–1696. mm6304a5.htm Centers for Disease Control and Prevention. (2016). Ocean, lakes, Hlavsa, M.C., Roberts, V.A., Kahler, A.M., Hilborn, E.D., Mecher, & rivers. Retrieved from https://www.cdc.gov/healthywater/swim- T.R., Beach, M.J., . . . Yoder, J.S. (2015). Outbreaks of illness asso- ming/oceans-lakes-rivers/index.html ciated with recreational water — United States, 2011–2012. Mor- Craun, G.F., Calderon, R.L., & Craun, M.F. (2005). Outbreaks asso- bidity and Mortality Weekly Report, 64(24), 668–672. Retrieved ciated with recreational water in the United States. International from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6424a4. Journal of Environmental Health Research, 15(4), 243–262. htm?s_cid=mm6424a4_w Dziuban, E.J., Liang, J.L., Craun, G.F., Hill, V., Yu, P.A., Painter, J., Jones, E.L., Gaither, M., Kramer, A., & Gerba, C.P. (2009). An analy- . . . Beach, M.J. (2006). Surveillance for waterborne disease and sis of water quality in the Colorado River, 2003–2004: An inves- outbreaks associated with recreational water—United States, tigation into recurring outbreaks of norovirus among rafters. Wil- 2003–2004. Morbidity and Mortality Weekly Report Surveillance derness & Environmental Medicine, 20(1), 6–13. Summaries, 55(SS12), 1–24. Retrieved from http://www.cdc.gov/ Malek, M., Barzilay, E., Kramer, A., Camp, B., Jaykus, L.A., Escu- mmwr/preview/mmwrhtml/ss5512a1.htm dero-Abarca, B., . . . Widdowson, M.A. (2009). Outbreak of noro- Harwood, V.J., Levine, A.D., Scott, T.M., Chivukula, V., Lukasik, J., virus infection among river rafters associated with packaged deli- Farrah, S.R., & Rose, J.B. (2005). Validity of the indicator organ- catessen meat, Grand Canyon, 2005. Clinical Infectious Diseases, ism paradigm for pathogen reduction in reclaimed water and 48(1), 31–37. public health protection. Applied and Environmental Microbiology, National Environment Methods Index. (n.d.). Standard meth- 71(6), 3163–3170. ods online: Enzyme substrate coliform test: 9223B enzyme sub- Hill, V.R., Kahler, A.M., Jothikumar, N., Johnson, T.B., Hahn, D., & strate test. Retrieved from https://www.nemi.gov/methods/ Cromeans, T.L. (2007). Multistate evaluation of an ultrafiltration- method_summary/5583/ based procedure for simultaneous recovery of enteric microbes in Northwest River Forecast Center. (n.d.). River information and 100-liter tap water samples. Applied and Environmental Microbiol- forecasts. Washington, DC: National Oceanic and Atmospheric ogy, 73(13), 4218–4225. Correction in Applied and Environmental Administration. Retrieved from http://www.nwrfc.noaa.gov/river/ Microbiology, 73(19), 6327. Retrieved from http://aem.asm.org/ station/flowplot/flowplot.cgi?midi1 content/73/19/6327.short Ntshoe, G.M., Malaza, A., Prentice, E., Tint, K.S., Ndugulile, F., & Hlavsa, M.C., Roberts, V.A., Anderson, A.R., Hill, V.R., Kahler, A.M., Harris, B. (2009). Diarrhoeal disease outbreak during a school Orr, M., . . . Yoder, J.S. (2011). Surveillance for waterborne disease white water rafting trip—Zambezi River, August 2008. Commu- outbreaks and other health events associated with recreational nicable Diseases Surveillance Bulletin, 7(2), 12–15. Retrieved from water—United States, 2007–2008. Morbidity and Mortality Weekly http://www.nicd.ac.za/assets/files/CommDisBullMay09_Vol0702. Report Surveillance Summaries, 60(SS12), 1–32. Retrieved from pdf http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6012a1.htm Outdoor Foundation. (2014). Outdoor recreation participation Hlavsa, M.C., Roberts, V.A., Kahler, A.M., Hilborn, E.D., Wade, topline report 2014. Washington, DC: Author. Retrieved from T.J., Backer, L.C., & Yoder, J.S. (2014). Recreational water- http://www.outdoorfoundation.org/pdf/ResearchParticipa associated disease outbreaks—United States, 2009–2010. Mor- tion2014Topline.pdf bidity and Mortality Weekly Report, 63(1), 6–10. Retrieved from Seitz, S.R., Leon, J.S., Schwab, K.J., Lyon, G.M., Dowd, M., McDan- http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6301a2. iels, M., . . . Moe, C.L. (2011). Norovirus infectivity in humans htm?s_cid=mm6301a2_w and persistence in water. Applied and Environmental Microbiology, 77(19), 6884–6888.

20 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 20 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

References U.S. Department of Agriculture, Forest Service. (2015). Required Yoder, J.S., Blackburn, B.G., Craun, G.F., Hill, V. , Levy, D.A., Chen, equipment details and tips for Middle Fork boaters. Retrieved from N., . . . Beach, M.J. (2004). Surveillance for waterborne-disease http://www.fs.usda.gov/detail/scnf/recreation/wateractivities/?cid outbreaks associated with recreational water—United States, =stelprdb5302658 2001–2002. Morbidity and Mortality Weekly Report Surveillance U.S. Department of Agriculture, Forest Service. (2017). Float- Summaries, 53(SS08), 1–22. Retrieved from http://www.cdc.gov/ ing the Middle Fork of the Salmon River. Retrieved from http:// mmwr/preview/mmwrhtml/ss5308a1.htm www.fs.usda.gov/detail/scnf/recreation/wateractivities/?cid=stelp Yoder, J.S., Hlavsa, M.C., Craun, G.F., Hill, V. , Roberts, V. , Yu, P.A., rdb5302105 . . . Beach, M.J. (2008). Surveillance for waterborne disease U.S. Environmental Protection Agency, Pesticide Registration. and outbreaks associated with recreational water use and other (2017). List G: EPA’s registered antimicrobial products effective aquatic facility-associated health events—United States, 2005– against norovirus. Retrieved from https://www.epa.gov/pesticide- 2006. Morbidity and Mortality Weekly Report Surveillance Summa- registration/list-g-epas-registered-antimicrobial-products-effec- ries, 57(SS09), 1–29. Retrieved from http://www.cdc.gov/mmwr/ tive-against-norovirus preview/mmwrhtml/ss5709a1.htm

Water quality is a major area of focus for NEHA. Our water quality page is Did You always being updated with new e-learning opportunities, relevant topics, and upcoming events and webinars. Check it out today and learn more at Know? www.neha.org/eh-topics/water-quality-0.?

When the moment is right . . . . FOR LAB WORK

T HINK LABORATORIES AIHA LA P, LLC AIHA LA P, LLC ACCREDITED LABORATORY ACCREDITED LABORATORY ENVIRONMENTAL MICROBIOLOGY INDUSTRIAL HYGIENE ISO/IEC 17025:2005 Food Safety, Microbiology and Environmental Professionals ISO/IEC 17025:2005 WWW.AIHAACCREDITEDLABS.ORG WWW.AIHAACCREDITEDLABS.ORG LAB # 1013525 LAB # 1013525

WWW.QUANTEM.COM l 800.822.1650 l WWW.QUANTEMFOOD.COM

July/August 2017 • Journal of Environmental Health 21

JEH7-8.17_PRINT.indd 21 6/15/17 3:29 PM ADVANCEMENT OF THE SCIENCE

Incidence of Non-Hodgkin

Lymphoma and Residential W. Brent Webber, DrPH, CIH, CSP Environmental Health and Safety Division, Proximity to Superfund Sites University of Kentucky in Kentucky Ramona Stone, MPH, PhD College of Public Health, University of Kentucky

located in proximity to Superfund sites, sometimes designated as “high exposure” areas, Abstract The rates of non-Hodgkin lymphoma (NHL) in have higher reports of neurological symptoms Kentucky and the U.S. began to rise in the mid-20th century. Plausible than areas with lower exposure (Dayal, Gupta, mechanistic explanations exist for linkages between the development of NHL Trieff, Maierson, & Reich, 1995). Meta-anal- and exposures to specific chemicals. Several of these chemicals are present in ysis showed that serum immunoglobulin A levels were consistently, but not significantly, sites within the U.S. Environmental Protection Agency’s Superfund program. elevated for residents near Superfund sites This study investigated a possible association between residential proximity compared with matched controls at least to Superfund sites in Kentucky and incidence of NHL over a period of 18 5 miles away from sites (Williamson et al., years. Cumulative incidence rates per 100,000 persons were calculated at 2006). Elevated incidence rates for multiple the census tract level, within 5 km–10 km and <5 km from Superfund sites. cancers were also found in areas neighboring a Superfund site in Massachusetts (Ozonoff, Geographically weighted regression was necessary to create best-fitting Aschengrau, & Coogan, 1994). Another models due to spatial autocorrelation and nonstationarity. Residential study estimated that multistate Superfund site proximity to Superfund sites in Kentucky was associated with higher cleanup activities reduced the rate of infant incidence of NHL; the average cumulative incidence of NHL per 100,000 congenital abnormalities by 20% to 25% for decreased as the distance to the hazardous sites increased. This study mothers who resided 5 km or less from the sites (Currie, Greenstone, & Moretti, 2011). confirmed previous research findings of an association between residential Tree bark samples within 10 km of a Super- proximity to environmentally hazardous sites and the cumulative incidence fund site in Michigan showed 10- to 100-fold rates of NHL. Future research should take into account the chemical profile increases in dichlorodiphenyltrichloroethane of each site, to identify the most hazardous sites. Potential intervention (DDT), hexabromobenzene, and polybromi- nated biphenyls compared with sites located strategies are presented based on the results of this study. beyond 10 km (Peverly, Salamova, & Hites, 2014). Geospatial analysis was used to identify clusters of childhood cancer near Superfund Introduction of specific chemical substances into the envi- sites in Dade County, Florida (Kearney, 2008), Non-Hodgkin lymphoma (NHL) is currently ronment, although support for such an asso- of very low birth weight near multiple Super- the eighth most common cancer in the U.S., ciation is difficult to establish. Xenobiotics can fund sites in Harris County, Texas (Thompson, the sixth most common cancer among males, function as immune system suppressors and Bissett, & Sweeney, 2014), and to investigate and the seventh most common cancer among immune suppression is a primary known risk and confirm the unequal burden of Superfund females (U.S. Cancer Statistics Working factor for NHL (Engels et al., 2005; Freeman & sites among specific racial, ethnic, and socio- Group, 2016). Kentucky has the fourth high- Kohles, 2012; Grulich, Vajdic, & Cozen, 2007; economic demographics (Burwell-Naney et est NHL death rate (National Cancer Institute, Vajdic et al., 2009). Exposures to lymphoma- al., 2013; Heitgerd & Lee, 2003; Maantay, 2014), and parallels the national and interna- genic substances can trigger immunosup- 2002; Maranville, Ting, & Zhang, 2009; Pais, tional Western trends of increased incidence pressive conditions (Fisher & Fisher, 2004), Crowder, & Downey, 2014). The siting of in the mid-20th century across all sexes and although persons with a history of allergies, Superfund sites in neighborhoods with lower age groups, with the highest overall rates seen other hyperimmune disorders, or asthma value housing disproportionately affects poor in White males (Al-Hamadani et al., 2015; appear to have a reduced risk of developing and primarily minority populations (Green- Devesa & Fears, 1992). The rise in NHL inci- NHL (Hofmann, Hoppin, Blair, Alavanja, stone & Gallagher, 2008; Ringquist, 2005; dence, in the U.S. and Kentucky, appears to & Freeman, 2014; Pahwa et al., 2012; Zhou Smith, 2009; Szasz & Meuser, 1997; Szasz & coincide with the increased use and dispersion & Yang, 2015). Residential neighborhoods Meuser, 2000).

22 Volume 80 • Number 1 ADVANCEMENT OF THE SCIENCE

al., 2014). Studies that examined NHL rates near uranium milling operations in New TABLE 1 Mexico (Boice, Mumma, & Blot, 2010) and Descriptive Statistics for Patient Data (N = 14,373) rates for a specific type of NHL (cutaneous T-cell lymphoma) in Pennsylvania (Moreau, Demographics # % Buchanich, Geskin, Akilov, & Geskin, 2014) did not show higher rates near hazardous Gender sites. Various state and federal health agen- Female 6,978 48.5 cies have been tasked to examine possible Male 7,395 51.5 NHL clusters near Superfund sites, and con- Race firmed higher than expected rates of NHL in White 13,617 94.7 all populations near sites in Ohio (Ferron & Black 632 4.4 Frey, 2008), Texas (Texas Department of State Health Services, 2015), California (Greater Other/unknown 124 0.9 Bay Area Cancer Registry, 2012), and in Age at diagnosis (year) females near a site in Connecticut (State of 0–9 61 0.4 Connecticut Department of Public Health, 10–19 127 0.9 1997). 20–29 221 1.5 30–39 583 4.1 Methods Following approval of the Institutional 40–49 1,300 9.0 Review Board of the University of Kentucky, 50–59 2,392 16.6 NHL cancer data for 1995–2012, including 60–69 3,546 24.7 14,373 records, were obtained from the Ken- ≥70 6,143 42.7 tucky Cancer Registry (KCR). All individual Tumor type identifying data, except for the geographic Intranodal NHL 10,181 70.8 coordinates for the patients’ residence, were removed by KCR staff. While 82.3% of NHL Extranodal NHL 4,192 29.2 cases could be assigned to census tracts based Family history of NHL on high-quality residential geospatial coordi- No 7,495 52.2 nates, the remaining 17.7% used the centroid Yes 533 3.7 of residential ZIP code because the patient’s Unknown 6,345 44.1 recorded address was on rural routes or a Appalachia region post office box. Census Tract Topologically Integrated Geo- No 10,337 71.9 graphic Encoding and Referencing (TIGER) Yes 4,036 28.1 file and basic population data were obtained Beale Code classification from the 2010 U.S. Census website; 734 of Urban 12,997 90.4 the 1,115 census tracts in Kentucky had Rural 1,376 9.6 incident cases of NHL at some time between 1995–2012. On average, census tracts in Residential proximity to nearest superfund site (km) Kentucky had 4,105 people (standard devia- <5 4,225 29.4 tion [SD] = 1,721) with a median of 3,920 5–10 3,570 24.8 people. The 18-year cumulative number of >10 6,578 45.8 NHL cases per 100,000 at census tract-level was on average 210 (SD = 336) with a median NHL = non-Hodgkin lymphoma. value of 28.5. The 1995–2012 crude cumulative incidence rate for NHL in Kentucky was 331.2 per 100,000 people, while the adjusted There are only a few published studies on U.S. Environmental Protection Agency (U.S. rate was 305.2 per 100,000 people. the possible link between residential proxim- EPA) Toxics Release Inventory resulted in a The environmental exposure was mea- ity to hazardous waste sites and NHL can- significant increase in NHL incidence (Bulka sured by proximity to one or more Super- cer cases. One study in Georgia found that et al., 2013). Another found that NHL rates fund sites in Kentucky. There were 133 residential proximity to areas where benzene were significantly elevated near National Pri- Superfund sites for which geospatial data had been released and documented in the ority Contaminated Sites in Italy (Comba et was available on the U.S. EPA Superfund

July/August 2017 • Journal of Environmental Health 23 ADVANCEMENT OF THE SCIENCE website for Region 4 (U.S. EPA, 2017); 970 census tracts in Kentucky did not have a TABLE 2 Superfund site within their borders, and the remaining 145 had one to five Super- Distribution of Non-Hodgkin Lymphoma (NHL) Cases by Exposure Group fund sites per tract. The exposure areas were developed in ArcMap by drawing 5 km and Demographic Variable Residential Proximity to Nearest Superfund Site 10 km buffers around each Superfund site. # (%) When buffers of neighboring Superfund <5 km 5–10 km >10 km sites intersected, they were dissolved into a single area of exposure, and the perimeter Gender Male 2,170 (29.4) 1,793 (24.2) 3,432 (46.4) of all of the conjoined buffers became the Female 2,055 (29.4) 1,777 (25.5) 3,146 (45.1) boundary of the newly created exposure Race White 3,826 (28.1) 3,400 (25.0) 6,391 (46.9) areas. Similarly, the 10 km buffers form a Non-White 351 (55.4) 133 (21.0) 150 (23.7) ring around the 5 km exposure areas. There- Appalachia region No 3,459 (33.5) 3,070 (29.7) 3,808 (36.8) fore, the exposure areas have different sizes Yes 766 (19.0) 500 (12.4) 2,770 (68.6) and shapes, including different numbers of census tracts or fragments of census tracts, Beale Code classification Urban 4,157 (32.0) 3,497 (26.9) 5,343 (41.1) and different numbers of Superfund sites Rural 68 (4.9) 73 (5.3) 1,235 (89.8) within their boundaries. Family history of NHL Yes 133 (25.0) 130 (24.4) 270 (50.7) There were 71 areas of exposure within 5 No 2,234 (29.8) 1,817 (24.2) 3,444 (46.0) km of one or more Superfund sites, and 45 Unknown 1,858 (29.3) 1,623 (25.6) 2,864 (45.1) areas located in the ring around the buffers SEER type Intranodal 2,969 (29.2) 2,547 (25.0) 4,665 (45.8) between 5 km–10 km. For the census tract fragments with missing values, the same Extranodal 1,256 (30.0) 1,023 (24.4) 1,913 (45.6) cumulative incidence rate of the exposure SEER = Surveillance, Epidemiology, and End Results Program of the National Cancer Institute. area was imputed. Finally, the remaining areas of the state, outside the 5 km and 10 km exposure areas, formed the third area of interest, the “unexposed” areas of the state, TABLE 3 for which the incidence rates were computed at census tract-level. Age-Adjusted 1995–2012 Cumulative Non-Hodgkin Lymphoma (NHL) The outcome of interest in this study is Incidence Rates by Exposure the age-adjusted cumulative incidence rate of NHL per 100,000 persons in Kentucky. Age-Adjusted NHL Exposure ANOVA The age-adjusted cumulative rates of NHL Incidence Rates Mean (SD) were estimated with the direct method for <5 km 5–10 km >10 km F-Statistic p-Value the exposure areas and for all census tracts Overall 457.0 (244.7) 308.6 (100.6) 90.9 (215.7) 17.8 <.001 outside the exposure areas, using the 2000 Male 542.4 (341.2) 338.3 (113.3) 25.8 (249.5) 21.6 <.001 U.S. Census standard population weights per Female 382.9 (240.2) 285.3 (116.7) 62.4 (303.6) 5.1 .006 100,000 per current recommendations from the Centers for Disease Control and Preven- Intranodal tumor 323.4 (200.2) 218.7 (73.3) 08.5 (180.6) 12.3 <.001 tion (Anderson & Rosenberg, 1998; Klein & Extranodal tumor 133.7 (82.8) 89.9 (49.6) 82.5 (76.6) 13.4 <.001

Schoenborn, 2001). The patient’s residential SD = standard deviation proximity to Superfund sites was measured by the exposure within 5 km, exposure between 5 km and 10 km, as compared with was measured with spatial regression. Race, Results the exposure beyond 10 km, which was the smoking status, and NHL family history were There were 14,373 new NHL cases in Ken- reference group for the analyses. tested in the bivariate models but were not tucky between 1995–2012 (Table 1), of which Traditional statistics were used to describe retained in the multivariable models due to 42.7% were diagnosed at age 70 or later and the patient population, and to test for bivari- the very small variation in the data and large another 24.7% were diagnosed with NHL in ate associations between the incidence rates proportions of missing values. Diagnostic their 60s; over 90% of the NHL patient popula- and potential explanatory factors available tools for spatial autocorrelation and cluster- tion resided in urban areas. The patient popu- in the dataset. The multivariable association ing confirmed the need for a geographically lation included 51.5% males and 94.7% of all between the exposure and the cumulative weighted regression approach. cases were White. Intranodal NHL accounted incidence rate of NHL per 100,000 persons for 70.8% of all cases, 71.7% of male cases, and

24 Volume 80 • Number 1 ADVANCEMENT OF THE SCIENCE

in rural areas. Finally, 39.1% of patients were current users of tobacco products. FIGURE 1 Bivariate analysis of residential proxim- Cumulative Non-Hodgkin Lymphoma (NHL) Incidence Rate ity to Superfund sites by demographic vari- per 100,000 People, Kentucky, 1995–2012 ables is presented in Table 2. Nearly 30% of all patients lived within 5 km of a Superfund NHL Age-Adjusted site; non-White NHL patients were more Per 100,000 People likely to live within 5 km of the Superfund 0–150 151–300 sites, whereas residents of Appalachia or rural 301–450 areas were less likely to live near them. The 451–600 601–3,011 percentage of NHL cases with unknown or no family history of NHL were significantly higher for the cases residing within 5 km of Superfund sites. The age-adjusted cumulative NHL incidence rates across exposure groups were significantly greater within 5 km exposure areas than in the other two groups (Table

0 62.5 125 250 Kilometers 3); further, the rates within 5 km and 10 km from the Superfund sites were significantly Sources: U.S. Census 2000, 2010 Kentucky Cancer Registry, greater than the rates in the unexposed areas. U.S. Environmental Protection Agency The rates for the unexposed group were significantly lower than those in the exposed groups, at a significance level ofp < .05. These data reflect the national trends, in FIGURE 2 that the male patients have a higher inci- Hot Spot Analysis for Cumulative Non-Hodgkin Lymphoma (NHL) dence rate than females for both intrano- Incidence Rate per 100,000 People dal and extranodal NHL. As expected, an age-related increase in NHL incidence was NHL Adjusted Rate observed for both males and females, and Cold Spot, 99% Confidence for both SEER classifications (Surveillance, Cold Spot, 95% Confidence Epidemiology, and End Results [SEER] Pro- Cold Spot, 90% Confidence Not Significant gram of the National Cancer Institute), with Hot Spot, 90% Confidence a sharp increase in NHL for females ages Hot Spot, 95% Confidence Hot Spot, 99% Confidence 60–69. The age-adjusted cumulative incidence rates for NHL per 100,000 persons from 1995–2012 in each census tract and buf- fer zone around Superfund sites (Figure 1) showed that NHL cumulative incidence rates were slightly higher in the western and south-central regions of Kentucky. Stationarity tests showed that the predictor effects on the outcome were not consis- 0 62.5 125 250 Kilometers tent across the studied area, and the Global Moran’s I indicated the presence of spatial Sources: U.S. Census 2000, 2010 Kentucky Cancer Registry, autocorrelation among residuals. All z-scores U.S. Environmental Protection Agency were significant and positive, indicating significant autocorrelation and clustering of similar residual values. Hot spot analysis 69.9% of female cases. Of all cases that were Only 3.7% of the patients had a known prior identified the areas of significant high or of other than White race, only 0.6% were His- family history of NHL and 52.2% had no prior low spatial clustering of NHL incidence data

panic or Latino of any race (data not shown) family history; data were missing for 44.1% using the Getis-Ord Gi* statistic at the 99%, and 4.4% were African American. In accor- of the caseload. Only 28.1% of patients lived 95%, and 90% confidence limits (Figure 2). dance with national NHL statistics, 67.4% of all in counties that were part of the designated Exploratory regression using ordinary diagnoses occurred in patients age 60 or older. region of Appalachia and 9.6% of patients lived least squares (OLS) showed that urbanicity

July/August 2017 • Journal of Environmental Health 25 ADVANCEMENT OF THE SCIENCE or rurality of an area is a significant predictor for the NHL cumulative incidence rate—but residence in the Appalachian region was not TABLE 4 (data not shown). This finding is interesting, Geographically Weighted Regression Modeling Results as the Appalachian region is generally known to have significantly higher cancer incidence Model Variables # of Sigma Akaike’s R2 rates than the rest of the state. The OLS mod- Neighbors Information els explained a small amount of the variabil- Criterion ity around the fitted regression line, with a Model 1 Exposure <5 km 241 155.809 24,893.804 0.231 coefficient of determination of about 7%; Exposure 5–10 km they had acceptable levels for the variance Model 2 Appalachia region 834 163.244 25,047.162 0.134 inflation coefficients, but significant Koenker Beale Code (BP) statistics indicate nonconsistent rela- Exposure <5 km Exposure 5–10 km tionships between the dependent and independent variables (nonstationarity); thus, Dependent variable: cumulative incidence of non-Hodgkin lymphoma per 100,000 people. geographically weighted regression (GWR) was more appropriate than the OLS models. For GWR models, adaptive kernel density estimation was utilized, along with the cor- FIGURE 3 rected Akaike information criterion (AIC) to estimate bandwidth. The AIC’s values Geographically Weighted Regression (GWR) Standardized Residuals, were compared between the GWR models; 1995–2012 Age-Adjusted Cumulative Non-Hodgkin Lymphoma the lower AIC value was from the GWR all- Incidence Rates per 100,000 People case base model (AIC = 24,893.8), indicating GWR Standardized Results that this was the model that best fits the data (SD = standard deviation) (Table 4). The GWR models represent a bet- < -1.5 SD ter fit around the regression line than the OLS -1.5 to < -0.50 SD -0.50 to < 0.50 SD models, and explain a larger percentage of the 0.50 to < 1.5 SD variability. The best-fitting model explains 1.5 to 2.5 SD >2.5 SD approximately 23% of the variability in the overall NHL cumulative incidence rate. The best-fitting GWR model showed that the confidence interval CI[ ] rate per 100,000 persons was on average 120.7 (t = 62.59, p < .001) greater within 5 km from Super- fund sites than in the areas beyond 10 km, while all other variables were held constant. 0 62.5 125 250 Kilometers Similarly, within the areas located between 5 km–10 km the CI rate per 100,000 persons Sources: U.S. Census 2000, 2010 Kentucky Cancer Registry, was 45.9 (t = 30.37, p < .001) greater than U.S. Environmental Protection Agency in the unexposed areas. The patterns and magnitudes of residuals (Figure 3) are not surprising, given that the best-fitting GWR Discussion understand relationships between outcomes model explained only 23.1% of the variability This observational study of the distribution of and environmental variables, and to make in the dependent variable. There appear to be NHL in Kentucky aimed to identify whether inferences about exposure patterns (Brewer, more areas of “high” standardized residuals the distribution of NHL incident cases fol- 2006). The model data support the hypoth- than “low” standardized residuals; the high- lows a different pattern across the state in esis that residential proximity to Superfund est magnitude areas, where the observed inci- relationship with the location of Superfund sites in Kentucky explains a significant pro- dence rates exceeded the predicted rates by sites. To the investigators’ knowledge, this portion of variance in the distribution of the more than 2.5 standard deviations, were most question has not been previously exam- cumulative incidence rates of NHL, although prominent in the central and western areas ined in Kentucky, or anywhere else in the a large proportion still remains unexplained. of Kentucky. Low areas, where the observed U.S. while examining important covariates. There are limitations to the present study. incidence rates were lower than the predicted Geospatial information and tools in public The cancer records did not include individual rates, were randomly scattered throughout health research extended our ability to exam- indicators associated with the social determi- the state. ine spatial patterns within existing data, to nants of health. Socioeconomic and demo-

26 Volume 80 • Number 1 ADVANCEMENT OF THE SCIENCE

graphic variables at the census-tract level It should be noted that the U.S. EPA will 20th century, in a pattern that suggests greater from the 2010 U.S. Census were imputed, place a site on the Superfund list only if there exposure to chemicals might be a causal factor. however, and were not found to signifi- is a plausible threat to human health or the Mechanistic research suggests many pathways cantly contribute to the association between environment. All Superfund sites in the pres- by which chemicals and xenobiotics can trig- residential proximity to Superfund sites and ent study were considered as equally likely to ger NHL. The present study demonstrated that NHL incidence rate. The standardized GWR contribute environmental exposures that can residential proximity to hazardous waste sites in residuals and the R2 values suggest that there lead to NHL. This consideration could lead to Kentucky could be a significant risk factor for are other explanatory variables that contrib- exposure misclassification, which most likely NHL. Additional research, advocacy, and edu- ute to NHL incidence that were not captured biases the results toward the null. cation should focus on mechanisms of NHL in the current investigation due to high pro- Education and awareness campaigns about incidence, replicating the present study in other portions of missing data regarding the family NHL, risk factors, and symptoms could lead contexts and with monitoring data. Further history of cancer, smoking, or alcohol use. to earlier diagnosis and better outcomes in research needs to be done to address upstream For the 133 Superfund sites in Kentucky, affected communities. Early detection relies on factors that lead to unequal burdens of hazard- data on the site-specific chemicals that led to techniques such as lymph node biopsy, blood ous material exposures and NHL incidences. the site’s Superfund designation were avail- cell chemistry and morphology tests, or imag- Additionally, downstream education and aware- able for only 20 (15.0%) of the sites. Of these ing scans that can detect not just NHL but ness, plus better methods for NHL screening 20 sites with chemical data available, 18 con- other hematological malignancies (University and early detection, are also needed. tained contaminants that have been associ- of Texas, MD Anderson Cancer Center, 2017). ated with an increased risk of NHL, including Encouraging people in the communities most Acknowledgements: The authors wish to benzene and benzyl compounds (Mehlman, affected by NHL to seek screening may improve thank Eric Durbin and Jaclyn Nee at the 2006), lead (Demir et al., 2011), polychlori- their health outcomes. Medical research should Kentucky Cancer Registry for providing the nated biphenyls (Müller, Ihorst, Mertelsmann, continue to investigate simple, low-cost, sensi- cancer records and for their availability to & Engelhardt, 2005), cadmium (Kelly et al., tive, and specific methods for detecting NHL, answer questions as they arose. 2013), trichloroethylene (Bassig, Lan, Roth- as it will most likely continue to be a cancer of man, Zhang, & Zheng, 2012), organochlo- high incidence as the population ages. Corresponding Author: W. Brent Webber, rines other than polychlorinated biphenyls Senior Industrial Hygienist, Environmental (Brown, Rushton, & British Occupational Conclusion Health and Safety Division, University of Ken- Cancer Burden Study Group, 2012), and per- NHL incidence in the U.S. and many other tucky, 252 East Maxwell Street, Lexington, KY chloroethylene (Vlaanderen et al., 2013). Western nations increased throughout the 40508. E-mail: [email protected].

References Al-Hamadani, M., Habermann, T.M., Cerhan, J.R., Macon, W.R., Brown, T., Rushton, L., & British Occupational Cancer Burden Maurer, M.J, & Go, R.S. (2015). Non-Hodgkin lymphoma sub- Study Group. (2012). Occupational cancer in Britain. Haemato- type distribution, geodemographic patterns, and survival in the poietic malignancies: Leukaemia, multiple myeloma, non-Hodg- US: A longitudinal analysis of the National Cancer Data Base kin’s lymphoma. British Journal of Cancer, 107(Suppl. 1), S41–S48. from 1998 to 2011. American Journal of Hematology, 90(9), Bulka, C., Nastoupil, L.J., McClellan, W., Ambinder, A., Phillips, A., 790–795. Ward, K., . . . Flowers, C.R. (2013). Residence proximity to ben- Anderson, R., & Rosenberg, H.M. (1998). Report of the second zene release sites is associated with increased incidence of non- workshop on age adjustment: National Center for Health Statis- Hodgkin lymphoma. Cancer, 119(18), 3309–3317. tics. Vital and Health Statistics, 4(30), 1–37. Burwell-Naney, K., Zhang, H., Samantapudi, A., Jiang, C., Dale- Bassig, B.A., Lan, Q., Rothman, N., Zhang, Y., & Zheng, T. (2012). marre, L., Rice, L., . . . Wilson, S. (2013). Spatial disparity in the Current understanding of lifestyle and environmental factors and distribution of Superfund sites in South Carolina: An ecological risk of non-Hodgkin lymphoma: An epidemiological update. Jour- study. Environmental Health, 12(96). nal of Cancer Epidemiology, 2012, 1–27. Comba, P., Ricci, P., Iavarone, I., Pirastu, R., Buzzoni, C., Fusco, M., Boice, J.D., Jr., Mumma, M.T., & Blot, W.J. (2010). Cancer incidence . . . ISS-AIRTUM Working Group for the study of cancer inci- and mortality in populations living near uranium milling and dence in contaminated sites. (2014). Cancer incidence in Italian mining operations in Grants, New Mexico, 1950–2004. Radiation contaminated sites. Annali dell’Istituto Superiore di Sanità, 50(2), Research, 174(5), 624–636. 186–191. Brewer, C.A. (2006). Basic mapping principles for visualizing cancer Currie, J., Greenstone, M., & Moretti, E. (2011). Superfund clean- data using geographic information systems (GIS). American Jour- ups and infant health. The American Economic Review, 101(3), nal of Preventive Medicine, 30(2), S25–S36. 435–441. continued on page 28

July/August 2017 • Journal of Environmental Health 27 ADVANCEMENT OF THE SCIENCE

References continued from page 27 Dayal, H., Gupta, S., Trieff, N., Maierson, D., & Reich, D. (1995). trations of cadmium and lead and the risk of B-cell non-Hodgkin’s Symptom clusters in a community with chronic exposure to lymphoma and multiple myeloma: A nested case-control study. chemicals in two Superfund sites. Archives of Environmental PLoS One, 8(11), e 81892. Retrieved from http://journals.plos.org/ Health, 50(2), 108–111. plosone/article?id=10.1371/journal.pone.0081892 Demir, C., Demir, H., Esen, R., Sehitogullari, A., Atmaca, M., & Alay, Klein, R., & Schoenborn, C.A. (2001). Age adjustment using the M. (2011). Altered serum levels of elements in acute leukemia 2000 projected U.S. population. Healthy People 2010 Statistical cases in Turkey. Asian Pacific Journal of Cancer Prevention, 12(12), Notes, 20, 1–10. 3471–3474. Maantay, J. (2002). Mapping environmental injustices: Pitfalls and Devesa, S.S., & Fears, T. (1992). Non-Hodgkin’s lymphoma time potential of geographic information systems in assessing envi- trends: United States and international data. Cancer Research, ronmental health and equity. Environmental Health Perspectives, 52(Suppl. 19), 5432s–5440s. 110(Suppl. 2), 161–171. Engels, E.A., Cerhan, J.R., Linet, M.S., Cozen, W., Colt, J.S, Davis, Maranville, A.R., Ting, T-.F., & Zhang, Y. (2009). An environmental S., . . . Hartge, P. (2005). Immune-related conditions and immune- justice analysis: Superfund sites and surrounding communities in modulating medications as risk factors for non-Hodgkin’s lym- Illinois. Environmental Justice, 2(2), 49–58. phoma: A case-control study. American Journal of Epidemiology, Mehlman, M.A. (2006). Causal relationship between non-Hodgkin’s 162(12), 1153–1161. lymphoma and exposure to benzene and benzene-containing sol- Ferron, P. & Frey, R. (2008). Health Consultation: Initial United States vents. Annals of the NewYork Academy of Sciences, 1076, 120–128. Environmental Protection Agency Investigation, Behr VOC Plume Moreau, J.F., Buchanich, J.M., Geskin, J.Z., Akilov, O.E., & Geskin, Site, Dayton, Montgomery County, Ohio. Columbus, OH: Ohio L.J. (2014). Non-random geographic distribution of patients with Department of Health, Health Assessment Section. Retrieved from cutaneous T-cell lymphoma in the Greater Pittsburgh area. Der- https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/eh/HAS/ matology Online Journal, 20(7), 1. Retrieved from http://escholar Behr/Behrphase1USEPA.pdf?la=en ship.org/uc/item/4nw7592w Fisher, S.G., & Fisher, R.I. (2004). The epidemiology of non-Hodg- Müller, A.M., Ihorst, G., Mertelsmann, R., & Engelhardt, M. (2005). kin’s lymphoma. Oncogene, 23(38), 6524–6534. Epidemiology of non-Hodgkin’s lymphoma (NHL): Trends, geo- Freeman, M.D., & Kohles, S.S. (2012). Plasma levels of polychlori- graphic distribution, and etiology. Annals of Hematology, 84(1), nated biphenyls, non-Hodgkin lymphoma, and causation. Journal 1–12. of Environmental and Public Health, 2012, 1–15. Retrieved from National Cancer Institute: Surveillance, Epidemiology, and End http://www.hindawi.com/journals/jeph/2012/258981/ Results Program. (2014). Section: Non-Hodgkin lymphoma. Table Greater Bay Area Cancer Registry. (2012). Cancer concern among resi- 19.22: Age-adjusted cancer death rates by state, all races, 2007– dents of a neighborhood in Mountain View, California: Report on can- 2011, males and females [archived page]. Retrieved from http:// cer incidence from the Greater Bay Area Cancer Registry. Retrieved seer.cancer.gov/archive/csr/1975_2011/browse_csr.php?sectionS from http://media.nbcbayarea.com/documents/Technical+Report EL=19&pageSEL=sect_19_table.22.html +Santa+Clara+Co+Cancers.pdf Ozonoff, D., Aschengrau, A., & Coogan, P. (1994). Cancer in the Greenstone, M., & Gallagher, J. (2008). Does hazardous waste mat- vicinity of a Department of Defense Superfund site in Massachu- ter? Evidence from the housing market and the Superfund Pro- setts. Toxicology and Industrial Health, 10(3), 119–141. gram. The Quarterly Journal of Economics, 123(3), 951–1003. Pahwa, M., Harris, S.A., Hohenadel, K., McLaughlin, J.R., Spinelli, Grulich, A.E., Vajdic, C.M., & Cozen, W. (2007). Altered immunity J.J., Pahwa, P., . . . & Blair, A. (2012). Pesticide use, immunologic as a risk factor for non-Hodgkin lymphoma. Cancer Epidemiology, conditions, and risk of non-Hodgkin lymphoma in Canadian Biomarkers & Prevention, 16(3), 405–408. men in six provinces. International Journal of Cancer, 131(11), Heitgerd, J.L., & Lee, V.C. (2003). A new look at neighborhoods 2650–2659. near National Priorities List sites. Social Science & Medicine, Pais, J., Crowder, K., & Downey, L. (2014). Unequal trajectories: 57(6), 1117–1126. Racial and class differences in residential exposure to industrial Hofmann, J., Hoppin, J., Blair, A., Alavanja, M., & Freeman, L.B. hazard. Social Forces, 92(3), 1189–1215. (2014). 0105 Farm exposures, allergy symptoms and risk of non- Peverly, A.A., Salamova, A., & Hites, R.A. (2014). Air is still con- Hodgkin lymphoma in the Agricultural Health Study. Occupa- taminated 40 years after the Michigan Chemical plant disaster in tional & Environmental Medicine, 71(Suppl. 1), A11. St. Louis, Michigan. Environmental Science & Technology, 48(19), Kearney, G. (2008). A procedure for detecting childhood cancer 11154–11160. clusters near hazardous waste sites in Florida. Journal of Environ- Ringquist, E.J. (2005). Assessing evidence of environmental inequi- mental Health, 70(9), 29–34. ties: A meta-analysis. Journal of Policy Analysis and Management, Kelly, R.S., Lundh, T., Porta, M., Bergdahl, I.A., Palli, D., Johansson, 24(2), 223–247. A.-S., . . . Chadeau-Hyam, M. (2013). Blood erythrocyte concen-

28 Volume 80 • Number 1 ADVANCEMENT OF THE SCIENCE

References Smith, C.L. (2009). Economic deprivation and racial segregation: U.S. Cancer Statistics Working Group. (2016). United States cancer Comparing Superfund sites in Portland, Oregon and Detroit, statistics: 1999–2013 incidence and mortality web-based report. Michigan. Social Science Research, 38(3), 681–692. Atlanta, GA: U.S. Department of Health and Human Services, Cen- State of Connecticut Department of Public Health (1997). Southing- ters for Disease Control and Prevention, National Cancer Institute. ton Cancer Incidence Study: Health information on hazardous waste Retrieved from https://nccd.cdc.gov/uscs/toptencancers.aspx sites. Retrieved from http://www.ct.gov/dph/lib/dph/environmen U.S. Environmental Protection Agency. (2017). Search for Superfund tal_health/eoha/atsdr/srscancerincidencefactsheet1997.pdf sites where you live. Retrieved from http://www.epa.gov/superfund/ Szasz, A., & Meuser, M. (1997). Environmental inequalities: Lit- search-superfund-sites-where-you-live erature review and proposals for new directions in research and Vajdic, C.M., Falster, M.O., de Sanjose, S., Martinez-Maza, O., theory. Current Sociology, 45(3), 99–120. Becker, N., Bracci, P.M., . . . Grulich, A.E. (2009). Atopic disease Szasz, A., & Meuser, M. (2000). Unintended, inexorable: The pro- and risk of non-Hodgkin lymphoma: An InterLymph pooled anal- duction of environmental inequalities in Santa Clara County, Cal- ysis. Cancer Research, 69(16), 6482–6489. ifornia. American Behavioral Scientist, 43(4), 602–632. Vlaanderen, J., Straif, K., Pukkala, E., Kauppinen, T., Kyyrönen, P., Texas Department of State Health Services. (2015). Assessment of Martinsen, J.I., . . . Weiderpass, E. (2013). Occupational exposure the occurrence of cancer, East Harris County, Texas 1995–2012. to trichloroethylene and perchloroethylene and the risk of lym- Retrieved from https://www.dshs.state.tx.us/epitox/CancerClusters/ phoma, liver, and kidney cancer in four Nordic countries. Occu- East-Harris-County-2015.doc pational and Environmental Medicine, 70(6), 393–401. Thompson, J.A., Bissett, W.T, & Sweeney, A.M. (2014). Evaluating Williamson, D.M., White, M.C., Poole, C., Kleinbaum, D., Vogt, geostatistical modeling of exceedance probability as the first step R., & North, K. (2006). Evaluation of serum immunoglobulins in disease cluster investigations: Very low birth weights near toxic among individuals living near six Superfund sites. Environmental Texas sites. Environmental Health, 13(47). Retrieved from http:// Health Perspectives, 114(7), 1065–1071. ehjournal.biomedcentral.com/articles/10.1186/1476-069X-13-47 Zhou, M.-H., & Yang, Q.-M. (2015). Association of asthma with the University of Texas, MD Anderson Cancer Center (2017). Non- risk of acute leukemia and non-Hodgkin lymphoma. Molecular Hodgkin’s lymphoma diagnosis. Retrieved from https://www.mdan and Clinical Oncology, 3(4), 859–864. derson.org/cancer-types/non-hodgkins-lymphoma/non-hodg kins-lymphoma-diagnosis.html

Thank you for Supporting the NEHA/AAS Scholarship Fund

American Academy of LeGrande G. Beatson George A. Morris, RS LCDR James Speckhart, MS Sanitarians Farmville, VA Dousman, WI Silver Spring, MD Lawrenceville, GA Bruce Clabaugh Richard L. Roberts Leon Vinci, DHA, RS James J. Balsamo, Jr., MS, MPH, Highlands Ranch, CO Grover Beach, CA Roanoke, VA MHA, RS, CP-FS Metairie, LA

Choosing a career that protects the basic necessities like food, water, and air for people in your communities already proves that you have dedication. Now, take the REHS/RS next step and open new doors with the Registered Environmental Health Specialist/ Registered Sanitarian (REHS/RS) credential from NEHA. It is the gold standard in environmental health and shows your commitment to excellence—to yourself and the communities you serve. Find out if you are eligible to apply at neha.org/rehs. A credential today can improve all your tomorrows.

July/August 2017 • Journal of Environmental Health 29 0 ﬁgures, 0 tables

ADVANCEMENT OF THE PRACTICE

 SPECIAL REPORT

Beneﬁts of a Study Abroad Element in the Environmental Health Curriculum

Timothy J. Ryan, PhD, CIH, CSP Ohio University

tional perspectives into the classrooms.” Sev- eral states with historically strong teacher col- Most populations now derive benefits as well as Abstract lege education systems now host universities risks from a global economy. Local environmental health can be impacted offering globally oriented teacher preparation positively through importation or adoption of foreign technological courses as well. These schools include Indi- advances, administrative approaches, and cultural attributes, to name ana University, Michigan State, Ohio State, only a few. Similarly, risks are now commonly shared on an international and the University of Wisconsin. Environ- mental health topics for study in such cur- scale, as illustrated by cross-border food source contamination, emerging riculums are many, and include global health or recognized disease spread, unchecked international pollution, and a host matters such as the pandemic flu, HIV/AIDS, of other incidents in recent years. Beyond the case study, historical record natural disasters and emergency response, of the textbook approach, affordable study abroad programs now exist to and global warming. more concretely educate students about such impacts. Once considered At the college level, the academic case has been clearly articulated for the skills and simply a perquisite for more financially able students, or a requirement for expertise of the environmental health profes- language arts students, both short- and full-term study abroad programs sional in matters with cross-border implica- increasingly add a necessary global perspective to the college environmental tions. The National Environmental Health health graduate. This special report details the ways in which a number of Science and Protection Accreditation Coun- accredited programs are using and integrating study abroad experiences into cil (EHAC) mandates educational content on the subject of emergency response and the their curriculums to better prepare their graduates to meet the international oftentimes-related disaster management of environmental health and safety challenges of the 21st century. environmental health issues (EHAC, 2010). In their college-level textbook on public health, Tulchinsky and Varavikova (2008) Introduction [IIE], 2016a). Students come from a diverse provide a clear listing of the impacts global Experience, travel—these are as education array of academic study areas. For the most events can have on domestic and interna- in themselves. recent academic year reported (2014–2015), tional environmental health practitioners. — Euripides, 480 B.C.–406 B.C. the greatest numbers were from science, These events include natural disasters such As the impact of globalization affects our technology, engineering, and math (24%); as hurricanes, droughts and famine, floods, social, political, and environmental systems, business (20%); social sciences (17%); for- earthquakes, and the ongoing repercussions study abroad opportunities have increasingly eign languages (8%); and fine and applied of volcanic eruptions. They go on to cite a become an academic priority both for stu- arts (7%) (IIE, 2016b). In total, 313,415 U.S. role for environmental specialists in the dents and for the college programs in which students went abroad to study in the 2014– preparation and organization of services for they are enrolled (Blake-Campbell, 2014). 2015 academic year, roughly a 3% increase human-initiated situations such as wars (ref- Formerly populated mostly by language stud- from the preceding year (IIE, 2016b). ugee camps), population displacements (as ies or cultural exchange students, long-term It will probably surprise few that global per- seen recently as a result of the ongoing Syrian study abroad programs are in decline relative spectives are being assimilated into the K-12 civil war migration), and other disruptions of to the growth of programs of shorter duration curriculum of U.S. schools. According to the civil societies worldwide (“Migrant crisis,” (Dwyer & Peters, 2000), with almost 2 out of National Education Association (2010), 2015). Frumkin (2016), in his text focus- every 3 study abroad courses lasting less than “three states—California, North Carolina, ing exclusively on environmental health, 8 weeks (Institute of International Education and Ohio—are starting to integrate interna- dedicates four chapters to the international

30 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 30 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTICE

aspects of population, climate change, war, study abroad location selected to fully appre- provide potable water to the population; they and issues in low-resource countries. ciate the multifaceted aspects of such an envi- visit the John Snow Pub, located just feet away ronmental health problem. Clearly there exist from the very site of the infamous water well Methods and Experiences modern cities where air pollution could be and pump (reconstructed nearby, sans han- Clearly, academicians are aware of and taught with the benefit of real-world, pres- dle) implicated by Snow in the 1850s cholera addressing global environmental health ent day examples: Mexico City, Beijing, and outbreaks; students take a water taxi down impacts. The purpose of this special report, Mumbai all represent cities with serious pol- the River Thames to Greenwich, observing however, is to highlight how a so-called lution demonstrating adverse health effects. centuries old (but still in operation) water “boots on the ground” curricular element can London, with its incredibly long history of outfalls into that tidal river, in turn emptying enhance and improve environmental health development, presents notable air pollution into the ocean; the class attends the London education in the U.S. Several examples will incidents from the past, like the Great Smog Science Museum observing a contemporane- be explored, including sustainability in Costa (Laskin, 2006), as well as modern techno- ous diorama of an early microbiology labo- Rica, air pollution in London, and climate logical and political approaches to abatement ratory significant for the identification and change in the Pacific. (Greater London Authority, 2017). In this control of infectious diseases. Although there Sustainability is perhaps the best example regard, London constitutes a prima facie case are many additional examples, these suffice of an immensely significant modern effort where seamless integration of the environ- to demonstrate how “the past can be made essentially unheard of 50 years ago. It has mental health message with the study abroad present” in a suitably located and prepared steadily grown in importance to the U.S. location is possible. As students ride one of study abroad experience. global community since its adoption here in the city’s more famous tourist attractions— In a directly analogous approach to that of the late 1960s (U.S. Environmental Protection the London Eye Ferris wheel—they are chal- the London course, students enrolled in the Agency, 2017). The concept and attractive- lenged to identify modern and historically author’s Global Public Health—Costa Rica ness of sustainability are widely recognized significant sources of pollution that unfold class get to personally experience environ- by numerous corporations, nongovernmen- before their eyes as the wheel takes them over mentally significant aspects of water pollu- tal organizations, universities, and govern- 400 feet above the city. At that height, the tion. As the class begins in the south of the ments. In their content analysis paper about thousands of now-defunct coal fired chimneys country, along the pristine Pacific Coast, stu- the International Research in Geographical demand to be seen, with their former impact dents live for a number of days on a small and Environmental Education, Kidman and (e.g., environmentally induced scrotal cancer, community water system. The realities of pro- Papadimitriou (2012) reported that papers as determined by Percivall Pott, or the Chim- viding fresh, potable water are experienced published by that journal related to environ- ney Sweepers Act of 1788) palpable through daily. On several class excursions, notably mental education increased threefold; those their sheer numbers. On the crowded streets the “sewer tour,” the class literally follows

papers following a theme of sustainability, below, thousands of mobile sources of NOx, the gray water discharges from a small com-

pollution, or global warming (10% of all pub- SOx, CO, etc., are equally apparent in the form munity through increasingly larger and more lished papers) showed a steady increase over of buses, heavy trucks, cars, motorcycles, and polluted streams, to the ultimate outfall at a the period 1992–2009. boats, while overhead the contrails from doz- tidal basin of the adjacent Pacific Ocean. In The University of Georgia is able to unam- ens of aircraft can be visualized under favor- this exercise, students are hard-pressed not to biguously demonstrate sustainability as it able atmospheric conditions. appreciate the importance of environmental relates to various co-ops and farms visited in One great strength of “being present” at a health regulations, the engineering advances Monteverde, Costa Rica, via its Comparative study abroad location, unlike a classroom, is employed for clean water provision, and con- Environmental Health Program. To connect the ability to connect in a meaningful way tamination control. students to this topic, farms in Georgia and with historical artifacts. While no one can Global climate change is a frequent, timely, Costa Rica are compared in terms of prod- re-live history or likely get close to the emo- and ever-present topic of concern and dis- ucts grown, methods (e.g., crop rotation, use tional feelings of an event years later, through cussion in multiple disciplines these days, of topography), and prospects for long-term seeing, handling, or visiting a historically sig- notably politics, engineering, and environ- sustainability. A tangible, intended learning nificant aspect of that event, it is entirely pos- mental health. What better way to illus- outcome of the study abroad aspect of the sible for the environmental health students trate to interested students the impacts of course is that students “are able to experience to create a modern memory intimately con- such changes, than to go to locations where classroom learning applied to local examples” nected to an ancient practice, event, or thing. they are evident? In the Costa Rica class, an through activities such as stopping along the In this way, the true impact of the past can article by researchers from the Centers for road and conversing with actual employees be experienced firsthand (for the student) in Disease Control and Prevention on environ- or farmers in the area (A.M. Zimeri, personal their own individual context. mental effects of global climate change (Patz communication, October 14, 2015). In the aforementioned London study & Frumkin, 2005) is read as part of a class In the author’s Global Public Health—Lon- abroad course, examples of just this sort of exercise. Students must then reflect upon the don course, the topic of air pollution is regu- phenomena are designed into the course. content of the reading (e.g., temperature, sea larly covered. For this topic, it is arguable if Students visit the British Museum and see an level rise, greenhouse gases, marine systems, there could be a more historically significant early lead pipe constructed by the Romans to vectorborne disease effects, etc.) and relate

July/August 2017 • Journal of Environmental Health 31

JEH7-8.17_PRINT.indd 31 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTICE

the content to the environment in which they impressed upon new professionals, however, health curriculum seems surprising given the are staying. Evidence of the absolute con- is the rapidly developing, interdependent, universality of environmental health. Given nection between this course element and the and inescapably globally linked nature of the trend of more readily available, shorter- study-abroad experience was evident when a many modern endeavors. For example, over term (i.e., less expensive) international study student commented in her paper about the 10 years ago, the U.S. Department of Com- abroad opportunities, this lack of acknowl- receding sea life normally found around the merce pointed out that 20% of jobs in the U.S. edgment is surprising. Quoting Dwyer and shoreline snorkeling reef. She reported that a were tied to international trade (U.S. Census Peters (2000) in their survey of past study local resident had noted that shoreline water Bureau, 2005). As of their updated accounting abroad participants: temperatures were rising, causing formerly for 2011, this percentage had risen to almost In the 1950s and 1960s, 72 percent of plentiful coral and its associated marine life 24%, or roughly 1 out of every 4 jobs in our respondents studied for a full year, but to recede to off-shore deeper water. Most rel- nation (U.S. Census Bureau, 2013). Notable only 20 percent of respondents did so in evant to this discussion is that the student jobs with obvious environmental health the 1990s. The number of students study- in fact went snorkeling in the affected area, impacts are represented categorically in this ing for less than 10 weeks tripled from visualized the dead reef areas, and could see data as Food, Beverages, and Chemicals, with the 1950s and the 1960s to the 1990s. more opulent life further off shore, precisely international employment links reported as For the majority of short-term programs, as the resident had noted (M. Reichert, per- 8.4%, 3.3%, and 30.3%, respectively. the most significant expenses are airfare and sonal communication, January 3, 2015). Some benefits of study abroad could transportation, followed by housing (which Finally, it might be pointed out that equally be seen stateside, if only they were typically involves more expensive lodg- environmental-oriented travel is no longer encouraged, required, or more frequent. The ing like hotels or leased apartment blocks, exclusively the domain of college students University of Georgia’s Professor Anne Marie as opposed to the home-stay model used in academic programs. In 2015, a Google Zimeri noted that the “shadowing” activity in learning languages). The actual educa- search listed seven discrete, independent of farm workers employed in her Costa Rica tion piece is rarely a significant expense in tour providers for the Chernobyl reactor site course led to more intense, real-life obser- that tuition and fees are considered part of and contamination zone in Ukraine. Other vations for a given topic back home (A.M. an existing academic term. For example, a so-called “dark tourism” sites exist, includ- Zimeri, personal communication, October spring break 10-day program will typically be ing Fukushima as well as a variety of envi- 14, 2015). Clearly the field trips used in considered within the spring semester. Many ronmental (receding glaciers, volcanoes) and U.S. environmental health education, or the schools provide for “free” credits so long as a nonenvironmental sites (shipwrecks, WWII practicum requirement of many curricula, student is enrolled as a full-time student (e.g., battlefields, etc.). can result in a similar intensity and oppor- 12 credit minimum) and does not exceed an While such tours are not stand-alone tunity for learning. Yet the immersive nature upper bound (e.g., 20 credits). In this struc- study abroad courses, it is foreseeable that of a study abroad course is itself a more pas- ture, study abroad is clearly a bargain for the they might be included in these if deemed sionate experience, leading to more powerful student, who would have living expenses in of interest to the course program director. impressions and lasting lessons, and provides any event, can take advantage of “free” cred- What is perhaps most interesting about such “a rich and engaging opportunity for stu- its, and therefore only needs to plan for the tours, however, is that they exist at all. They dents to learn firsthand” (Blake-Campbell, added expense of airfare to complete the present clear evidence of a fascination among 2014, p. 62). study abroad learning experience. a variety of backgrounds to see and better While the benefits of environmental As a final point for an environmentally understand a specific environmental health health-focused study abroad experiences are conscious profession such as ours, it must story. As such, their very existence consti- clear and demonstrable, cost is an inescap- also at least be acknowledged that any adop- tutes a highly relevant illustration of an envi- able reality that generally limits any wide- tion of more active global education must ronmental health-centered type of learning. spread requirement (or even allowance) for remain sensitive to the impacts such activi- In the case of Chernobyl, for instance, what their occurrence. Whereas prescriptive envi- ties might have on the visited sites. For any better way to bring home to those travelers ronmental health curricula from EHAC man- environmental health study abroad offering, the application and importance of the long- date coursework in toxicology, epidemiology, the question of how environmental quality standing aspects of radiation safety of time, and statistics, study abroad has yet to be men- might be affected by the mere presence of distance, and shielding. tioned in the undergraduate environmen- the students should be considered prior to tal health program accreditation guidelines travel. Any sort of “environmental paradox” Discussion (EHAC, 2010). Cost could easily be a factor in which the study of an environmental topic That the global perspective of environmen- for their exclusion. The EHAC guidelines are could be seen to jeopardize local residents, tal health is shared by most practitioners of just that—guidelines—and are regarded as their environment, or quality of life at the the profession will come as no surprise to quite flexible when utilized in a determina- study site should carefully be considered. many, as the National Environmental Health tion of a program’s suitability for accredita- For example, Skanavis and Sakellari (2011) Association itself has offered global train- tion or reaccreditation. Nevertheless, the point out that more developed countries are ing exchange opportunities for its mem- wholesale lack of acknowledgement for the responsible for the majority of greenhouse bers for years (NEHA, 2015). What must be benefits of study abroad in the environmental gas emissions, but the worst consequences

32 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 32 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTICE

are felt in countries “lacking the economic self-confidence, developed their maturity, its attendant environmental influences) are capacity and infrastructure to cope.” For an and had a lasting impact on their worldview. all highly pertinent examples in which the environmental health curriculum, one should (Equally positive results were confirmed in present-day environmental health practitio- consider if the course impact in terms of car- 2012 by Preston.) From the environmental ner requires sensitivity to the international bon footprint, transportation emissions, and health perspective, such a worldview can be picture. As such, inclusion of more glob- food, water, and waste provision justify the considered helpful—if not outright essen- ally focused study abroad provided-learning learning provided by the experience. tial—in a world of global interactivity and experiences from the modern environmental interdependence. For example, in the after- health curriculum must make their way to Conclusion math of the localized Japanese earthquake the students of present day environmental In a published survey that was not peer and resulting tsunami of March 11, 2011, the health programs. reviewed of 3,400 returned students from global economic and business impacts were 1950–1999, Dwyer and Peters (2000) point quickly felt (Bunkley, 2011). Food security Corresponding Author: Timothy J. Ryan, Pro- to positive and unequivocal benefits of all and sourcing, hazardous chemicals and mate- fessor, Occupational Hygiene and Safety Pro- study abroad experiences. Over 95% of all rials disposal, air pollution from stationary gram, Ohio University, W355 Grover Center, respondents responded affirmatively that and mobile sources, emergency response or Athens, OH 45701. E-mail: [email protected]. their time abroad taught them increased mitigation, and global climate change (with

References Blake-Campbell, B. (2014). More than just a sampling of study National Education Association. (2010). Policy brief: Global compe- abroad: Transformative possibilities at best. Community Col- tence is a 21st century imperative (PB28A). Washington, DC: NEA lege Enterprise, 20(2), 60–71. Retrieved from http://www.school Education Policy and Practice Department, Center for Great Pub- craft.edu/a-z-index/community-college-enterprise/search- lic Schools. Retrieved from http://www.nea.org/assets/docs/HE/ archives/425#.WPRl_45JnUp PB28A_Global_Competence11.pdf Bunkley, N. (2011, April 19). Toyota plans to reduce production for National Environmental Health Association. (2015). Sabbatical 6 weeks. The New York Times, p. B4. Retrieved from http://www. exchange program. nytimes.com/2011/04/20/business/global/20auto.html National Environmental Health Science and Protection Accredita- Dwyer, M.M., & Peters, C.K. (2000). The benefits of study abroad: tion Council. (2010). Undergraduate guidelines. Retrieved from New study confirms significant gains. Retrieved from https:// http://www.ehacoffice.org/accred-guide/under-guide.php www2.clarku.edu/offices/studyabroad/pdfs/IES%20Study.pdf Patz, J.A., & Frumkin, H. (2005). Climate change. In H. Frumkin Frumkin, H. (Ed.). (2016). Environmental health from global to local. (Ed.), Environmental health from global to local (pp. 275–316). San San Francisco, CA: Jossey-Bass. Francisco, CA: Jossey-Bass. Greater London Authority. (2017). Environment strategies and pub- Preston, K. (2012). The impact of studying abroad on recent college lications. Retrieved from https://www.london.gov.uk/what-we-do/ graduate’s careers. IES Abroad recent graduate survey: 2006–2011 environment/environment-strategies-and-publications graduates. Retrieved from http://www.iesabroad.org/system/files/ Institute of International Education. (2016a). Open Doors data recentgraduatessurvey.pdf U.S. study abroad: Duration of study abroad. Retrieved from Skanavis, C., & Sakellari, M. (2011). International tourism, domes- https://www.iie.org/Research-and-Insights/Open-Doors/Data/ tic tourism and environmental change: Environmental education US-Study-Abroad/Duration-of-Study-Abroad can find the balance. Tourismos: An International Multidisciplinary Institute of International Education. (2016b). Open Doors data Journal of Tourism, 6(1), 233–249. U.S. study abroad: Fields of study. Retrieved from https://www.iie. Tulchinsky, T.H., & Varavikova, E.A. (2008). Globalization of health. org/Research-and-Insights/Open-Doors/Data/US-Study-Abroad/ In The new public health (2nd ed., pp. 605–635). San Diego, CA: Fields-of-Study Elsevier Academic Press. Kidman, G., & Papadimitriou, F. (2012). Content analysis of inter- U.S. Census Bureau. (2005). Exports from manufacturing establish- national research in geographical and environmental education: ments. Washington, DC: U.S. Department of Commerce. 18 years of academic publishing. International Research in Geo- U.S. Census Bureau. (2013). Exports from manufacturing. Washing- graphical and Environmental Education, 21(1), 3–10. ton, DC: U.S. Department of Commerce. Retrieved from http:// Laskin, D. (2006). The great London smog. Weatherwise, 59(6), www.census.gov/mcd/exports/ 42–45. U.S. Environmental Protection Agency. (2017). What is the National Migrant crisis: Thousands stranded at Balkan borders. (2015, Oct. Environmental Policy Act? Retrieved from http://www2.epa.gov/ 19). BBC News Services. Retrieved from http://www.bbc.com/ nepa/what-national-environmental-policy-act news/world-europe-34568499

July/August 2017 • Journal of Environmental Health 33

JEH7-8.17_PRINT.indd 33 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTICE

 DIRECT FROM AAS

Cross-Training: It’s Not Just for Athletes!

Nancy Pees Coleman, MPH, PhD, RPS, REHS, DAAS Environmental Consultants

Cross-training can be a powerful tool for Editor’s Note: In an effort to provide environmental health profes- both the organization and the environmen- sionals with relevant information and tools to further the profession, their tal health professional. Just as the team and athlete benefi t from cross-training by having careers, and themselves, NEHA has teamed up with the American Academy better team members, environmental health of Sanitarians (AAS) to publish two columns a year in the Journal. AAS is an organizations are stronger and more effective organization that “elevates the standards, improves the practice, advances when their environmental health profession- the professional profi ciency, and promotes the highest levels of ethical als have more overall knowledge about environmental health and safety program areas. conduct among professional sanitarians in every fi eld of environmental A broader understanding of the program- health.” Membership with AAS is based upon meeting certain high standards matic areas encourages employees to use a and criteria, and AAS members represent a prestigious list of environmental more holistic approach when implementing health professionals from across the country. new projects, developing new regulatory programs, etc. It builds better teamwork within Through this column, information from different AAS members who are and among program areas as they begin to subject-matter expects with knowledge and experience in a multitude of understand why each is important to the environmental health topics will be presented to the Journal’s readership. overall mission of the organization. It also This column strengthens the ties between both associations in the shared makes an organization less vulnerable to disruptions due to employee departures, emer- purposes of furthering and enhancing the environmental health profession. gencies, illnesses, or unexpected workloads. Nancy Pees Coleman is an environmental toxicologist in private practice in For organizations that have compliance Oklahoma City, Oklahoma. She has degrees from Old Dominion University requirements, cross-training yields profession- and the University of Oklahoma Health Sciences Center. She has been a als that can identify issues beyond their individual subject. For example, the food service diplomate of AAS since 1988. inspector can recognize that an emergency generator installation at the food processing facility needs an air permit and may also need a thletes do it! Fitness trainers push partment, an environmental quality depart- spill prevention control and countermeasures it! It’s cross-training! Just as ath- ment, a consulting fi rm, and a corporation, plan, a lead-acid battery management plan, A letes are encouraged to pursue cross-training in the various disciplines an evaluation of potential employee exposure cross-training in more than one sport to im- of environmental health has been manda- to the combustion exhausts, and a hazardous prove fi tness and performance in their main tory for me to be effective in my position waste management plan. This comprehensive sport, environmental health professionals as a toxicologist. Forty years of profes- view can result in better overall environmental should be encouraged to cross-train in more sional practice have made me realize how health compliance. than one aspect of our discipline to improve important it is for an environmental health Considering the recent trend of manager overall competency and performance in en- professional to understand all the program placement over areas in which they have vironmental health. By the very nature of areas that intersect within environmental little or no competency, cross-training helps being the only toxicologist in a health de- health groups or departments. to build better managers. One of my sons

34 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 34 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTICE

worked for 20 years for a company that was opportunities lead to better design and imple- any of the duties or tasks associated with an divided into three major program areas. An mentation of new programs at the fi eld level. environmental health professional, including entry-level employee worked a minimum of For the individual employee, cross-train- general environmental health, food, water, 9–12 months in each of the program areas. ing makes them a more valuable asset to wastewater, waste management, hazardous Only then was an employee eligible to be pro- their organization and adds variety to their materials, air quality, housing, and occupa- moted to a management level. Each program work, which typically results in happier and tional safety and health. With this diversity area was managed for a year to gain experience more productive employees. Cross-training of duties and tasks in mind, continuing edu- managing each of the areas before becoming gives the employee an opportunity to build cation can offer great opportunities to incor- eligible for promotion to the next manage- new relationships with other environmen- porate cross-training. ment level. By the time someone reached tal health professionals in their organiza- One major challenge to cross-training is the upper levels of management, they knew tion, which enhances the team concept for the organizational structure of most envi- how to do every job in the company. Cross- the entire organization. Cross-training does ronmental health organizations, i.e., orga- training makes for better managers and bet- have to be implemented carefully to avoid nizations that are divided by environmental ter decision making by those managers. The employee concerns about being replaced or media or major regulatory areas. Person- major barrier to this rotational approach is their work not being satisfactory. nel and human relations systems are often the highly specialized and complex nature of Cross-training requires careful planning, not well suited to promote cross-training. environmental health tasks. It often takes a upper management support, and engaged Therefore, it requires managers to creatively year or more to bring a new professional up employees. The concepts of cross-training address ways to allow their environmental to a minimum level of competency. In these should be built into an environmental health health professionals to develop expertise in instances, cross-training could be accom- organization’s overall training plan with clear more than one subject area, such as the use plished by job sharing between employees on expectations and goals. To start, a series of of interdisciplinary workgroups for large a temporary basis (e.g., a couple of hours per “awareness” type training opportunities cov- projects or regulatory program development week), short duration assignments of two to ering all program areas in the environmental or the use of formalized mentoring arrange- four weeks, or a voluntary two-year rotation health organization could be developed and ments among program areas. plan. For highly specialized positions, cross- offered to employees. When planning your next year’s training cal- training may only cover a portion of the job This training could be augmented with endar or identifying the continuing education that can be reasonably shared. Internet-based training opportunities that to take in the coming year, consider cross-train- Cross-training can also be helpful between are often free and available for a wide vari- ing. It helps increase the overall sustainability fi eld environmental health professionals and ety of environmental health subject areas. and fl exibility of environmental health pro- those located in the central agency or corpo- Group participation in a webinar followed grams and departments. Although it requires rate offi ce. By nature of the job, fi eld envi- by a 30-minute facilitated discussion regard- consideration, planning, and effort on the part ronmental health professionals have more ing how the topic impacts or is handled by of environmental health organizations and pro- opportunity for on-the-job cross-training the organization could enhance the value fessionals, it is well worth the effort. because of the diverse programmatic respon- of the training. The use of problem-solving sibilities of their job. For employees in the oriented, multidisciplinary training activi- Corresponding Author: Nancy Pees Cole- central agency or corporate offi ce, fi eld and ties, such as tabletop exercises, can also be man, Principal, Environmental Consultants, multiple discipline cross-training helps them useful in cross-training. Most sanitarian and 11200 South Miller Avenue, Oklahoma City, understand the time requirements for accom- environmental health specialist registration OK 73170. plishing fi eld activities. These cross-training programs require continuing education in E-mail: [email protected].

Employers increasingly require a professional credential to verify that you are qualiﬁ ed and trained to perform your job duties. Credentials improve the visibility and credibility of our profession, and they can result in raises or promotions for the holder. For 80 years, NEHA has fostered dedication, competency, and capability through professional credentialing. We provide a path to those who want to challenge themselves, and keep learning every day. Earning a credential is a personal commitment to excellence and achievement. Learn more at neha.org/professional-development/credentials. A credential today can improve all your tomorrows.

July/August 2017 • Journal of Environmental Health 35

JEH7-8.17_PRINT.indd 35 6/15/17 3:29 PM 1 ﬁgure, 1 sidebar

ADVANCEMENT OF THE PRACTICE

 DIRECT FROM CDC ENVIRONMENTAL HEALTH SERVICES BRANCH

Understanding the Needs, Challenges, Opportunities, Vision, and Emerging Roles in Environmental Health Justin A. Gerding, Elizabeth Bryan W. Brooks, MPH, REHS Landeen PhD Centers for National Baylor University Disease Control Environmental and Prevention Health Association

Previous studies describing state, tribal, Editor’s Note: NEHA strives to provide up-to-date and relevant local, and territorial health departments information on environmental health and to build partnerships in the have addressed aspects of environmental health staffing and services, yet there re- profession. In pursuit of these goals, we feature a column from the mains a critical need to engage environ- Environmental Health Services Branch (EHSB) of the Centers for Disease mental health professionals with a method Control and Prevention (CDC) in every issue of the Journal. designed specifically for the environmental In these columns, EHSB and guest authors share insights and information health profession. In response, CDC, the about environmental health programs, trends, issues, and resources. The National Environmental Health Association, and Baylor University are partnering on an conclusions in this column are those of the author(s) and do not necessarily innovative initiative to characterize the en- represent the views of CDC. vironmental health profession and under- LCDR Justin Gerding is an environmental health specialist with stand the challenges environmental health CDC’s EHSB. Elizabeth Landeen is the associate director of Program professionals encounter. This effort, Under- and Partnership Development with the National Environmental Health standing the Needs, Challenges, Opportuni- Association. Bryan Brooks is a distinguished professor of environmental ties, Vision, and Emerging Roles in Environ- science and biomedical studies and director of environmental health mental Health (UNCOVER EH), presents an unprecedented opportunity to delve into the science at Baylor University. profession and understand environmental health professional demographics, education and training, experience, areas of prac- ika virus, Legionnaires’ disease, and to identify gaps in staffing, training, and tice, and the current and future needs of en- the Flint, Michigan, water crisis are ultimately, to ensure preparedness to meet vironmental health professionals. Z examples of diseases and events re- future challenges. The Centers for Disease Though the work of environmental quiring a response from a prepared, suffi- Control and Prevention’s (CDC) A National health professionals and the services they cient, and equipped environmental health Strategy to Revitalize Environmental Public deliver are critical to protect local com- workforce. While demands continue to in- Health Services, developed with input from munities, the profession often remains un- crease, diverse factors such as health depart- numerous environmental health stakehold- known to many until an event occurs and ment budget cuts and decreased capacity ers representing governmental, nongovern- appears on the front page of the newspaper can negatively impact environmental health mental, and academic organizations, identi- or the nightly news. An initiative like UN- professionals and programs (Association of fied the significance of conducting in-depth COVER EH has the potential to increase State and Territorial Health Officials, 2014; evaluations to ensure the existence of a awareness of the profession by obtaining National Association of County and City sufficient and well-trained environmental information directly from environmental Health Officials, 2013). These compound- health workforce with the capacity to pro- health professionals about their practice ing factors reinforce the need to under- vide quality services addressing community and the challenges they currently face and stand the environmental health workforce need (CDC, 2003). envision for the future. UNCOVER EH con-

36 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 36 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTICE

FIGURE 1 “Workforce evaluations are needed to ascertain the current level of competence, methods of training, effect of training, effect of the ‘essen- Understanding the Needs, Challenges, Opportunities, tial services’ approach to environmental public health, relations between Vision, and Emerging Roles competencies and practices as they pertain to community-based needs, in Environmental Health (UNCOVER EH) Logo information that reaches the environmental public health workforce, and effect of workforce-directed activities on the level of competence and job performance.” (p.19) — A National Strategy to Revitalize Environmental Public Health Services, Centers for Disease Control and Prevention (www.cdc.gov/nceh/ehs/publications/strategy.htm)

sists of two components—a comprehensive lowing the online survey, several in-person References online survey and facilitated in-person workshops will be held. The workshops Association of State and Territorial Health workshops. Modeled after horizon scan- will bring together environmental health Officials. (2014). Budget cuts continue to ning approaches, this methodology will professionals to review and distill the sur- affect the health of Americans. Retrieved lead to a thorough examination of the cur- vey findings and prioritize grand challeng- from http://www.astho.org/budget-cuts- rent workforce setting followed by identifi- es and future needs. Sept-2014 cation and prioritization of challenges and UNCOVER EH will result in a national- Boulton, M.L., Beck, A.J., Coronado, F. , Mer- needs (Brooks, Ankley, Boxall, & Rudd, level description and analysis of the envi- rill, J.A., Friedman, C.P., Stamas, G.D., . . . 2013). This phase of UNCOVER EH fo- ronmental health profession. The results of Leep, C.J. (2014). Public health workforce cuses on environmental health profession- this initiative will be made publicly available taxonomy. American Journal of Preventive als working at public health departments; in a comprehensive report. The report is in- Medicine, 47(5, Suppl. 3), S314–S323. however, there may be future opportunities tended to provide important information Brooks, B.W., Ankley, G.T., Boxall, A.B., & to expand the survey to include environ- for ensuring that the workforce is prepared Rudd, M.A. (2013). Toward sustainable mental health professionals at other gov- to address current and future environmen- environmental quality: A call to prioritize ernmental and nongovernmental agencies, tal health issues, as well as for shaping the global research needs. Integrated Environ- and in private industry. delivery of environmental health services mental Assessment and Management, 9(2), Efforts are underway to identify and and increasing positive health impacts. UN- 179–180. obtain e-mail addresses for environmen- COVER EH is scheduled to launch fall 2017 Centers for Disease Control and Preven- tal health professionals working at health with the release of the online survey. In the tion. (2003). A national strategy to revi- departments across the nation. The identi- meantime, environmental health profes- talize environmental public health services. fied individuals will receive an e-mail re- sionals are encouraged to watch for updates Retrieved from https://www.cdc.gov/nceh/ questing their voluntary participation and and help increase the awareness of this im- ehs/publications/strategy.htm will contain a unique web link to access portant initiative. It is crucial to hear from National Association of County and City the UNCOVER EH online survey. The sur- environmental health professionals across Health Officials. (2013). Local health de- vey was designed to collect essential infor- the nation to assure generalizable results partment job losses and program cuts: Find- mation about the needs of environmental and broad representation of environmental ings from the 2013 profile study. Retrieved health professionals, professional demo- health challenges, needs, and opportunities. from http://archived.naccho.org/topics/ graphics, education and training, areas of To learn more about UNCOVER EH, please infrastructure/lhdbudget/upload/Survey- practice, competencies, and the skills and visit www.neha.org/uncover-eh. Findings-Brief-8-13-13-3.pdf resources necessary to meet evolving and Sellers, K., Leider, J.P., Harper, E., Castrucci, emerging issues and challenges. The sur- Corresponding Author: Justin A. Gerding, B.C., Bharthapudi, K., Liss-Levinson, R., vey elements were designed to align with Environmental Health Services Branch, . . . Hunter, E.L. (2015). The public health established public health workforce frame- National Center for Environmental Health, workforce interests and needs survey: works and assessments (Boulton et al., Centers for Disease Control and Prevention, The first national survey of state health 2014; Sellers et al., 2015). The survey is 4770 Buford Highway NE, MS F-58, Atlanta, agency employees. Journal of Public Health expected to take approximately 30 minutes GA 30341. E-mail: [email protected]. Management and Practice, 21(Suppl. 6), to complete. The information collected will S13–S27. be aggregated for analysis, which prevents linking respondents to their responses. Fol-

July/August 2017 • Journal of Environmental Health 37

JEH7-8.17_PRINT.indd 37 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTITIONER EH CALENDAR

UPCOMING NEHA CONFERENCES Region Group member countries, Montego Bay, Jamaica. For more information, contact [email protected]. July 10–13, 2017: NEHA 2017 Annual Educational Conference Kansas & Exhibition, Grand Rapids, MI. For more information, visit October 11–13, 2017: Joint Annual Conference and Trade www.neha.org/aec. Show, hosted by the Kansas Environmental Health Association June 25–28, 2018: NEHA 2018 Annual Educational Conference and Kansas Small Flows Association, Wichita, KS. For more & Exhibition, Anaheim, CA. information, visit www.keha.us. July 8–11, 2019: NEHA 2019 Annual Educational Conference Minnesota & Exhibition, Nashville, TN. September 19–21, 2017: FDA Central Region Retail Food July 13–16, 2020: NEHA 2020 Annual Educational Conference Protection Seminar and NEHA Region 4 Biannual Educational & Exhibition, New York, NY. Conference, Minneapolis, MN. For more information, visit www.mehaonline.org. NEHA AFFILIATE AND REGIONAL LISTINGS New Jersey Alabama September 21, 2017: Annual Symposium, hosted by the New October 17–19, 2017: Annual Education Conference, hosted by Jersey Environmental Health Association, Edison, NJ. For more the Alabama Environmental Health Association, Mobile, AL. For information, visit www.njeha.org/events. more information, visit www.aeha-online.com. North Dakota Colorado October 17–19, 2017: Fall Education Conference, hosted by September 20–22, 2017: 63rd Annual Education Conference, the North Dakota Environmental Health Association. For more hosted by the Colorado Environmental Health Association, information, visit http://ndeha.org/wp/conferences. Colorado Springs, CO. For more information, visit Rhode Island www.cehaweb.com. October 4–5, 2017: 55th Annual Yankee Conference on Florida Environmental Health, Newport, RI. For more information, August 24–27, 2017: Annual Education Meeting, hosted by the visit www.cteha.org. Florida Environmental Health Association, Palm Harbor, FL. Tennessee For more information, visit www.feha.org. October 4–6, 2017: 71st Annual Interstate Environmental Illinois Health Seminar, hosted by the Tennessee Environmental Health October 19–20, 2017: Annual Educational Conference, hosted Association, Gatlinburg, TN. For more information, visit by the Illinois Environmental Health Association, East Peoria, IL. www.wvdhhr.org/wvas/IEHS/index.asp. For more information, visit http://iehaonline.org. Texas Indiana October 9–13, 2017: Annual Educational Conference, hosted by September 25–27, 2017: Fall Educational Conference, hosted the Texas Environmental Health Association, Austin, TX. by the Indiana Environmental Health Association, Lawrenceburg, For more information, visit www.myteha.org. IN. For more information, visit www.iehaind.org. Wisconsin Jamaica October 18–20, 2017: Joint Educational Conference, hosted by October 22–26, 2017: International Environmental Conference the Wisconsin Environmental Health Association, Sheboygan, and IFEH Council Meeting, hosted by the Jamaica Association of WI. For more information, visit www.weha.net. Public Health Inspectors in association with the IFEH Americas

The 2017 Integrated Foodborne Outbreak Response and Management (InFORM) Conference, November 6–9, brings together laboratorians, Did You epidemiologists, and environmental health specialists involved with foodborne and enteric disease outbreak response. The online abstract submission form for presentations and posters will be posted on July 3 and Know? will close on July 21. Learn more at www.aphl.org/conferences/InformConf/ Pages/2017-Inform-Conference.aspx.?

38 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 38 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTITIONER CAREER OPPORTUNITIES

Food Safety Inspector UL Everclean is a leader in retail inspections. We offer opportunities across the country. We currently have openings for trained professionals to conduct audits in restaurants and grocery stores. Past or current food safety inspection experience is required. United States Coeur d’Alene, ID Lexington, KY Rapid City, SD Wichita, KS Amarillo, TX Columbus, OH Little Rock, AR Rochester, NY Yuma, AZ Bakersﬁ eld, CA Eureka, CA Louisville, KY San Diego, CA Canada Billings, MT Grand Junction, CO Lubbock, TX Shreveport, LA British Columbia Boston, MA Grand Rapids, MI Midland, TX Sioux Falls, SD Toronto Buffalo, NY Honolulu, HI Odessa, TX St. Louis, MO Cedar Rapids, IA Idaho Falls, ID Owatonna, MN Syracuse, NY Cincinnati, OH Kansas City, MO/KS Philadelphia, PA Tulsa, OK If you are interested in an opportunity near you, please send your resume to ATTN Sethany Dogra at [email protected] or visit our Web site at www.evercleanservices.com.

You can share your event with the environmental health community by Did You posting it directly on our community calendar at www.neha.org/news- events/community-calendar. Averaging 2,000 page views a month, you are sure to bring a lot of attention to your event. Make sure to check it often, Know? and you might ﬁ nd a new event? happening in your area! Find a Job Fill a Job

Where the “best of the best” consult...

NEHA’s Career Center

First job listing FREE for city, county, and state health departments with a NEHA member, and for Educational and Sustaining members.

For more information, please visit neha.org/professional- development/careers

July/August 2017 • Journal of Environmental Health 39

JEH7-8.17_PRINT.indd 39 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTITIONER right rag RESOURCE CORNER

Resource Corner highlights different resources that NEHA has available to meet your education and training needs. These timely resources provide you with information and knowledge to advance your professional development. Visit NEHA’s online Bookstore for additional information about these, and many other, pertinent resources!

Handbook of Environmental Health, Volume 1: Handbook of Environmental Health, Volume 2: Biological, Chemical, and Physical Agents of Pollutant Interactions With Air, Water, and Soil Environmentally Related Disease (4th Edition) (4th Edition) Herman Koren and Michael Bisesi (2003) Herman Koren and Michael Bisesi (2003) A must for the reference library of anyone in A must for the reference library of anyone in the environmental health profession, this the environmental health profession, this book book focuses on factors that are generally focuses on factors that are generally associated associated with the internal environment. It with the outdoor environment. It was written was written by experts in the field and by experts in the field and copublished with copublished with the National Environmental the National Environmental Health Health Association. A variety of Association. A variety of environmental issues environmental issues are covered such as are covered such as toxic air pollutants and air food safety, food technology, insect and quality control; risk assessment; solid and rodent control, indoor air quality, hospital hazardous waste problems and controls; safe environment, home environment, injury control, pesticides, drinking water problems and standards; onsite and public sewage industrial hygiene, instrumentation, and much more. problems and control; plumbing hazards; air, water, and solid waste Environmental issues, energy, practical microbiology and programs; technology transfer; GIS and mapping; bioterrorism and chemistry, risk assessment, emerging infectious diseases, laws, security; disaster emergency health programs; ocean dumping; and toxicology, epidemiology, human physiology, and the effects of the much more. Study reference for NEHA’s Registered Environmental environment on humans are also covered. Study reference for Health Specialist/Registered Sanitarian credential exam. NEHA’s Registered Environmental Health Specialist/Registered 876 pages / Hardback Sanitarian credential exam. Volume 2: Member: $195 / Nonmember: $215 790 pages / Hardback Two-Volume Set: Member: $349 / Nonmember: $379 Volume 1: Member: $195 / Nonmember: $215 Two-Volume Set: Member: $349 / Nonmember: $379 Control of Communicable Diseases Manual (20th Edition) Modern Food Microbiology (7th Edition) Edited by David L. Heymann, MD (2015) James M. Jay, Martin J. Loessner, and David A. Golden (2005) The Control of Communicable Diseases Manual This text explores the fundamental elements (CCDM) is revised and republished every affecting the presence, activity, and control of several years to provide the most current microorganisms in food. It includes an information and recommendations for overview of microorganisms in food and what communicable-disease prevention. The CCDM allows them to grow; specific microorganisms is designed to be an authoritative reference for in fresh, fermented, and processed meats, public health workers in official and voluntary poultry, seafood, dairy products, fruits, health agencies. The 20th edition sticks to the vegetables, and other products; methods for tried and tested structure of previous editions. finding and measuring microorganisms and Chapters have been updated by international their products in foods; methods for experts. New disease variants have been preserving foods; food safety and quality controls; and foodborne included and some chapters have been fundamentally reworked. diseases. Other section topics include biosensors, biocontrol, bottled This edition is a timely update to a milestone reference work that ensures the relevance and usefulness to every public health water, Enterobacter sakazakii, food sanitizers, milk, probiotics, proteobacteria, quorum sensing, and sigma factors. Study reference professional around the world. The CCDM is a study reference for for NEHA’s Certified Professional–Food Safety credential exam. NEHA’s Registered Environmental Health Specialist/Registered Sanitarian and Certified Professional–Food Safety credential exams. 790 pages / Hardback 729 pages / Paperback Member: $84 / Nonmember: $89 Member: $59 / Nonmember: $64

40 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 40 6/15/17 3:29 PM ADVANCEMENT OF THE PRACTITIONER JEH QUIZ

FEATURED ARTICLE QUIZ #1

Outbreak Caused by Clostridium perfringens Infection and Intoxication at a County Correctional Facility

vailable to those holding an individual  Quiz deadline: October 1, 2017 7. The mean onset between exposure to the suspected A NEHA membership only, the JEH Quiz, meal and illness was offered six times per calendar year through the Journal of Environmental Health, is an easily 1. Approximately __ of foodborne outbreaks caused a. <1 hour. accessible means to accumulate continuing- by Clostridium perfringens occur in correctional b. 2.5 hours. education (CE) credits toward maintaining your facilities. c. 7 hours. NEHA credentials. d. 9 hours. 1. Read the featured article carefully. a. 5% 2. Select the correct answer to each JEH b. 7% 8. Confirmatory analyses determined that the following Quiz question. c. 11% contained C. perfringens enterotoxin except for 3. a) Complete the online quiz found at d. 15% a. chicken taco meat mixture. www.neha.org/publications/journal- b. rice with cheese sauce. environmental-health, 2. The following are foods most frequently associated c. beans. b) Fax the quiz to (303) 691-9490, or with outbreaks caused by C. perfringens except for d. flour tortillas. c) Mail the completed quiz to a. meats. JEH Quiz, NEHA b. meat products. 9. The occurrence of __ and __ might suggest 720 S. Colorado Blvd., Suite 1000-N c. gravy. toxin ingestion. Denver, CO 80246. C. perfringens d. vegetables. Be sure to include your name and a. nausea; vomiting membership number! 3. C. perfringens enterotoxin is inactivated at __ °F for b. nausea; fever 4. One CE credit will be applied to your __ minutes. c. fever; diarrhea account with an effective date of July 1, d. vomiting; diarrhea 2017 (first day of issue). a. 125; 5 5. Check your continuing education account b. 131; 16.3 10. Of the surveyed ill respondents, __ was the highest online at www.neha.org. c. 140; 5 indicated symptom. 6. You’re on your way to earning CE hours! d. 149; 0.9 a. nausea 4. Illness generally is caused when sufficient numbers b. abdominal cramps of C. perfringens are consumed and subsequently c. vomiting Quiz Registration produce toxins in the intestines. d. diarrhea a. True. 11. The chicken taco meat mixture demonstrated a __ b. False. Name odds ratio compared to the other menu items. 5. Of the 185 surveyed individuals who consumed a. lower lunch on April 15, 2012, __ of them were identified b. similar NEHA Member No. as ill according to the case definition. c. greater a. 29 12. Kent County Health Department concluded that the b. 58 chicken taco meat mixture was the most probable E-mail c. 76 cause of the foodborne illness outbreak. d. 108 a. True. 6. The actual number of sick inmates likely ranged b. False. between __ and __ based upon a Kent County Correctional Facility estimate and the projection JEH Quiz #5 Answers calculated by the survey attack rate, respectively. March 2017 a. 108; 185 1. b 4. c 7. c 10. a b. 108; 666 2. c 5. b 8. d 11. b c. 250; 666 3. a 6. a 9. c 12. b d. 250, 766

July/August 2017 • Journal of Environmental Health 41

JEH7-8.17_PRINT.indd 41 6/15/17 3:29 PM Corresponding Author and Subject Index Journal of Environmental Health ADVANCEMENT OF THE PRACTITIONER

Code Corresponding Author/Title Volume/Issue Keyword 1 Keyword 2 Keyword 3 Keyword 4 Keyword 5 1 Elizabeth Ablah, MPH, PhD, et al. 79.5 Community Environmental Hazardous Water Pollution A Community-Based Participatory Research Dec 2016 Nuisances/ Justice Materials/Toxic Control/Water Approach to Identifying Environmental Concerns Pages: 14–19 Safety Substances Quality 2 Karin L. Adams, PhD, et al. 79.4 Noise Occupational Recreational Noise Exposure and Temporary Hearing Loss Nov 2016 Health/Safety Environmental of Indoor Hockey Officials: A Pilot Study Pages: 22–26 Health 3 Paul J. Beggs, PhD, et al. 79.8 Disaster/ Institutions International Management/ Meteorology/ A Comparison of Heat Wave Response Plans April 2017 Emergency and Schools Policy Weather/ From an Aged Care Facility Perspective Pages: 28–37 Response Climate 4 Juanita Ebert Brand, MSN, EdD, RN, WHNP- 79.1 Public Health/ Research BC, et al. Jul/Aug 2016 Safety Methods Rewards and Lessons Learned From Pages: 20–23 Implementation of a Healthy Homes Research Project in a Midwestern Public Health Department 5 Jenifer Buckley, PhD 79.5 Education/ Food Workforce Interpersonal Skills in the Practice of Food Dec 2016 Training Development Safety Inspections: A Study of Compliance Pages: 8–12 Assistance 6 Benjamin Chapman, PhD, et al. 79.7 Food Media/ Public Health/ Going Public: Early Disclosure of Food Risks March 2017 Reporting Safety for the Benefit of Public Health Pages: 8–14 7 Aimin Chen, MD, PhD, et al. 79.3 Hazardous Lead Management/ Solid Waste Technology E-Waste Management in the United States Oct 2016 Materials/Toxic Policy and Public Health Implications Pages: 8–16 Substances 8 Joshua L. Clayton, MPH, PhD, et al. 79.10 Epidemiology Recreational Pools/Spas Water Quality Survey of Splash Pads After June 2017 Environmental a Waterborne Salmonellosis Outbreak— Pages: 8–12 Health Tennessee, 2014 9 Linda S. Cook, PhD, et al. 79.1 Epidemiology Hazardous Public Health/ Research Rural Community Viewpoint on Long-Term Jul/Aug 2016 Materials/Toxic Safety Methods Research Participation Within a Uranium Pages: E1–E4 Substances Mining Legacy, Grants Mining District, New Mexico 10 Gaurav Dhiman et al. 79.3 Microbiology Water Pollution Using Multiple-Antibiotic-Resistance Profiles Oct 2016 Control/Water of Coliforms as a Tool to Investigate Combined Pages: 36–39 Quality Sewer Overflow Contamination 11 Mary-Margaret A. Fill, MD, et al. 79.9 Epidemiology Pools/Spas Recreational Water Pollution Cryptosporidiosis Outbreak Associated With a May 2017 Environmental Control/Water Single Hotel Pages: 16–22 Health Quality 12 Angela Fraser, PhD, et al. 79.2 Emerging Institutions and Risk Environmental Factors Associated With Sept 2016 Pathogens Schools Assessment Norovirus Transmission in Long-Term Care Pages: 22–29 Facilities in South Carolina 13 Mary A. Fox, MPH, PhD, et al. 79.10 Management/ Public Health/ Technology Workforce Building the Future of Environmental June 2017 Policy Safety Development Public Health Tracking: Proceedings and Pages: 14–19 Recommendations of an Expert Panel Workshop 14 Hongxia Gao et al. 79.9 Hazardous International Risk Wastewater Water Pollution Pollution Characteristics and Potential May 2017 Materials/Toxic Assessment Control/Water Ecological Risk Assessment of Polycyclic Pages: E1–E6 Substances Quality Aromatic Hydrocarbons in Wastewater Irrigated Soil

Back issues are available for $15 each. To order, contact us at 303.756.9090, ext. 0, or [email protected].

42 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 42 6/15/17 3:29 PM Corresponding Author and Subject Index Journal of Environmental Health ADVANCEMENT OF THE PRACTITIONER Volume 79: July/August 2016–June 2017

Code Corresponding Author/Title Volume/Issue Keyword 1 Keyword 2 Keyword 3 Keyword 4 Keyword 5 15 Lydia B. Garcia, MPH, et al. 79.2 Drinking Water Environmental Water Pollution A Comparison of Water-Related Perceptions Sept 2016 Justice Control/Water and Practices Among West Texas and South Pages: 14–20 Quality New Mexico Colonia Residents Using Hauled- Stored and Private Well Water 16 Vijay Golla, MPH, PhD, et al. 79.5 Drinking Water Hazardous Atrazine in Kentucky Drinking Water: Dec 2016 Materials/Toxic Intermethod Comparison of U.S. Pages: E1–E6 Substances Environmental Protection Agency Analytical Methods 507 and 508.1 17 Ellen J. Hahn, PhD, RN, FAAN, et al. 79.6 Environmental Indoor Air Public Health/ Radiation/ Risk Lung Cancer Worry and Home Screening for Jan/Feb 2017 Justice Safety Radon Assessment Radon and Secondhand Smoke in Renters Pages: 8–13 18 Heather Henderson, MPH, DVM, et al. 79.7 Food Management/ Food Safety Program Performance March 2017 Policy Assessment in Tennessee, 2003–2011 Pages: 16–20 19 Zaccheaus Ayo Ibitoye, MSc, et al. 79.10 International Noise Public Health/ Risk Assessment of Noise Level Distributions June 2017 Safety Assessment in Lagos Metropolis and the Potential for Pages: E1–E5 Adverse Health Effects 20 Xu Jie et al. 79.3 Epidemiology Indoor Air International Public Health/ Indoor Environmental Factors Related to the Oct 2016 Safety Prevalence of Asthma and Asthma-Related Pages: E1–E8 Symptoms Among Adults During Summer in Zunyi, Guizhou Province, China 21 Stephen A. Kells, MS, PhD, BCE, et al. 79.7 Community Education/ Environmental Vector Control The Let’s Beat the Bug! Campaign—A March 2017 Nuisances/ Training Justice Statewide Active Public Education Against Bed Pages: 22–27 Safety Bugs in Minnesota 22 Jooho Kim, PhD, et al. 79.10 Education/ Food Management/ Public Health/ Consumer Perception of the Food and Drug June 2017 Training Policy Safety Administration’s Newest Recommended Food Pages: 20–25 Facility Inspection Format: Words Matter 23 Brett Koontz, DPA, REHS, et al. 79.4 Drinking Water Sustainability Water Pollution The Permitting of Desalination Facilities: A Nov 2016 Control/Water Sustainability Perspective Pages: 28–32 Quality 24 James D. Lane, MSc, et al. 79.1 Community International Noise Public Health/ Sustainability Impacts of Industrial Wind Turbine Noise on Jul/Aug 2016 Nuisances/ Safety Sleep Quality: Results From a Field Study of Pages: 8–12 Safety Rural Residents in Ontario, Canada 25 Jennifer C. Latimer, MS, PhD, et al. 79.3 Community Hazardous Lead Technology Soil Lead Testing at a High Spatial Resolution Oct 2016 Nuisances/ Materials/Toxic in an Urban Community Garden: A Case Study Pages: 28–35 Safety Substances in Relic Lead in Terre Haute, Indiana 26 Joon-hak Lee, PhD, et al. 79.1 Public Health/ Research Vector Control An Estimation of Potential Vector Control July/Aug 2016 Safety Methods Effect of Gravid Mosquito Trapping in Fort Pages: 14–19 Worth, Texas 27 Yuanan Lu, MS, PhD, et al. 79.7 Ambient Air Children’s International Public Health/ A Study of Parents’ Perception of Air Pollution March 2017 Environmental Safety and Its Effect on Their Children’s Respiratory Pages: E1–E9 Health Health in Nanchang, China 28 Jing Ma, PhD, et al. 79.10 Education/ Food Management/ Public Health/ Inspector Perceptions of the Food and Drug June 2017 Training Policy Safety Administration’s Newest Recommended Food Pages: 26–31 Facility Inspection Format: Training Matters 29 May A. Massoud et al. 79.8 International Management/ The Path to Informed Policies: Environmental April 2017 Policy Health Indicators and the Challenges of Pages: E1–E7 Developing a Surveillance System in Lebanon

July/August 2017 • Journal of Environmental Health 43

JEH7-8.17_PRINT.indd 43 6/15/17 3:29 PM Corresponding Author and Subject Index Journal of Environmental Health ADVANCEMENT OF THE PRACTITIONER

Code Corresponding Author/Title Volume/Issue Keyword 1 Keyword 2 Keyword 3 Keyword 4 Keyword 5 30 Lara B. McKenzie, MA, PhD, et al. 79.9 Education/ Indoor Air Public Health/ Distribution and Evaluation of a Carbon May 2017 Training Safety Monoxide Detector Intervention in Two Settings: Pages: 24–30 Emergency Department and Urban Community 31 Robert Newsad, MPH, et al. 79.4 Food Risk Assessed Food Safety Risks Associated With Nov 2016 Assessment Grocery Stores Pages: 16–21 32 Claudio R. Nigg, PhD, et al. 79.3 Children’s Education/ Institutions and Management/ Public Health/ A Review of Promising Multicomponent Oct 2016 Environmental Training Schools Policy Safety Environmental Child Obesity Prevention Pages: 18–26 Health Intervention Strategies by the Children’s Healthy Living Program 33 Kathleen G. Norlien, MS, CPH, et al. 79.9 Hazardous Occupational Occupational Health Survey of Cosmetologists May 2017 Materials/Toxic Health/Safety in Minnesota Pages: 8–14 Substances 34 Paschal Nwako, MPH, PhD, REHS, CHES, DAAS 79.6 Food Management/ Workforce The Effect of Inspection Announcement on Jan/Feb 2017 Policy Development the Outcome of Food Service Establishment Pages: 14–18 Sanitary Health Evaluations 35 Joy Onasch, MS, PE, et al. 79.6 Hazardous Occupational From Perchloroethylene Dry Cleaning to Jan/Feb 2017 Materials/Toxic Health/Safety Professional Wet Cleaning: Making the Health Pages: E1–E7 Substances and Business Case for Reducing Toxics 36 Kelsey J. Pieper, PhD, et al. 79.2 Drinking Water Public Health/ Water Pollution Simultaneous Inﬂuence of Geology and Sept 2016 Safety Control/Water System Design on Drinking Water Quality in Pages: E1–E9 Quality Private Systems 37 Eleoussa Polyzoi, PhD, et al. 79.7 Children’s Indoor Air Institutions and International Presence of Household Mold, Children’s March 2017 Environmental Schools Respiratory Health, and School Absenteeism: Pages: 28–35 Health Cause for Concern 38 M. Thomas Quail, MS, RN, LNC 79.6 Hazardous Occupational Overview of Silica-Related Clusters in the Jan/Feb 2017 Materials/Toxic Health/Safety United States: Will Fracking Operations Pages: 20–27 Substances Become the Next Cluster? 39 Stephanie L. Richards, MSEH, PhD, et al. 79.8 Occupational Risk Vector Control Residual Effectiveness of Permethrin-Treated April 2017 Health/Safety Assessment Clothing for Prevention of Mosquito Bites Pages: 8–15 Under Simulated Conditions 40 Paul A. Rosile, MPH, PhD, RS, et al. 79.8 Management/ Vector Control Novel Indices of Meteorological Drivers April 2017 Policy of West Nile Virus in Ohio Culex Species Pages: 16–22 Mosquitoes From 2002–2006 41 Douglas J. Schnoebelen, PhD, et al. 79.9 Drinking Water Management/ Public Health/ Water Pollution Elevated Arsenic in Private Wells of May 2017 Policy Safety Control/Water Cerro Gordo County, Iowa: Causes and Pages: 32–39 Quality Policy Changes 42 Derek Shendell, MPH, DEnv, et al. 79.2 Disaster/ Epidemiology Management/ Risk Terrorism/ Type II Diabetes Emergency Room Visits Sept 2016 Emergency Policy Assessment All-Hazards Associated With Hurricane Sandy in New Pages: 30–37 Response Preparedness Jersey: Implications for Preparedness 43 Christopher Sibrizzi, MPH, et al. 79.4 Hazardous Meteorology/ Sustainability Water Pollution An Assessment of Life Cycle Greenhouse Gas Nov 2016 Materials/Toxic Weather/ Control/Water Emissions Associated With the Use of Water, Pages: 8–15 Substances Climate Quality Sand, and Chemicals in Shale Gas Production of the Pennsylvania Marcellus Shale 44 Lisa Smestad, REHS, et al. 79.2 Lead Technology Machine Versus Man: Can Robotic Mops Clean Sept 2016 to Lead Safety Standards? Pages: 8–12

44 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 44 6/15/17 3:29 PM Corresponding Author and Subject Index Journal of Environmental Health ADVANCEMENT OF THE PRACTITIONER Volume 79: July/August 2016–June 2017

Code Corresponding Author/Title Volume/Issue Keyword 1 Keyword 2 Keyword 3 Keyword 4 Keyword 5 45 Mitsuo Uchida, MD, PhD, et al. 79.4 Epidemiology Indoor Air Institutions and International Risk Association Between Keeping Pet Animals and Nov 2016 Schools Assessment Allergic Rhinitis: A Case-Control Study Among Pages: E1–E8 Japanese University Students 46 Wendy C. Varnado, PhD, et al. 79.5 Management/ Vector Control Use of the VectorTest for Advanced Warning Dec 2016 Policy of Human West Nile Virus Cases in Mississippi Pages: 20–24 47 Caitlin Weems, MS, et al. 79.8 Meteorology/ Sustainability Reframing Climate Change for April 2017 Weather/ Environmental Health Pages: 24–27 Climate

Subject Corresponding Author/Title Code Ambient Air 27 Children’s Environmental Health 27, 32, 37 Community Nuisances/Safety 1, 21, 24, 25 Disaster/Emergency Response 3, 42 Drinking Water 15, 16, 23, 36, 41 Education/Training 5, 21, 22, 28, 30, 32 Emerging Pathogens 12 Environmental Justice 1, 15, 17, 21 Epidemiology 8, 9, 11, 20, 42, 45 Food 5, 6, 18, 22, 28, 31, 34 Hazardous Materials/Toxic Substances 1, 7, 9, 14, 16, 25, 33, 35, 38, 43 Indoor Air 17, 20, 30, 37, 45 Institutions and Schools 3, 12, 32, 37, 45 Cross Reference International 3, 14, 19, 20, 24, 27, 29, 37, 45 Lead 7, 25, 44 Management/Policy 3, 7, 13, 18, 22, 28, 29, 32, 34, 40, 41, 42, 46 Media/Reporting 6 Meteorology/Weather/Climate 3, 43, 47 Microbiology 10 Noise 2, 19, 24 Occupational Health/Safety 2, 33, 35, 38, 39 Pools/Spas 8, 11 Public Health/Safety 4, 6, 9, 13, 17, 19, 20, 22, 24, 26, 27, 28, 30, 32, 36, 41 Radiation/Radon 17 Recreational Environmental Health 2, 8, 11 Research Methods 4, 9, 26 Risk Assessment 12, 14, 17, 19, 31, 39, 42, 45 Solid Waste 7 Sustainability 23, 24, 43, 47 Technology 7, 13, 25, 44 Terrorism/All-Hazards Preparedness 42 Vector Control 21, 26, 39, 40, 46 Wastewater 14 Water Pollution Control/Water Quality 1, 10, 11, 14, 15, 23, 36, 41, 43 Workforce Development 5, 13, 34

July/August 2017 • Journal of Environmental Health 45

JEH7-8.17_PRINT.indd 45 6/15/17 3:29 PM National Environmental Health Association 82nd 2018 Annual Educational2018 ANationalE EnvironmentalC Health Association Annual Educational Conference ConferenceAnaheim &• California Exhibition • June 25-28, 2018 JUNE 25–28, 2018 Marriott Anaheim Hotel Anaheim, California visitanaheim.org THE DATE SAVE

NEHA 2018 AEC • neha.org/aec Grand Plaza, photoGrand courtsey of

JEH7-8.17_PRINT.indd 46 6/15/17 3:29 PM 2018_Save the Date_AEC.indd 1 6/12/17 1:21 PM National Environmental Health Association YOUR ASSOCIATION 82nd 2018 NEHA ORGANIZATIONAL MEMBERS

Sustaining Members EcoSure Nashua Department of Health Steritech Group, Inc. [email protected] http://nashuanh.gov/497/ www.steritech.com Annual Educational2018 Accela National Environmental Health Association Public-Health-Community-Services AEC www.accela.com Eljen Corporation Sweeps Software, Inc. Annual Educational Conference www.eljen.com National Environmental www.sweepssoftware.com Advanced Fresh Concepts Corp. Health Science and Protection Anaheim • California • June 25-28, 2018 Erie County Department of Texas Roadhouse Conference & Exhibition www.afcsushi.com Accreditation Council Health www.texasroadhouse.com Air Chek, Inc. www.ehacofﬁ ce.org www.erie.gov/health The University of Findlay www.radon.com New Mexico Environment Gila River Indian Community: www.ﬁ ndlay.edu Department Albuquerque Environmental Environmental Health Service Tri-County Health Department www.env.nm.gov JUNE 25–28, 2018 Health Department www.gilariver.org www.tchd.org www.cabq.gov/environmentalhealth New York City Department of GLO GERM/Food Safety First UL Health & Mental Hygiene Marriott Anaheim Hotel Allegheny County Health www.glogerm.com www.ul.com Department www.nyc.gov/health GoJo Industries Waco-McLennan County Public www.achd.net NSF International Anaheim, California www.gojo.com Health District American Chemistry Council www.nsf.org www.waco-texas.com/ Health Department of Northwest www.americanchemistry.com Omaha Healthy Kids Alliance cms-healthdepartment Michigan http://omahahealthykids.org Arlington County Public Health www.nwhealth.org Waukesha County Environmental Division Opportunity Council/Building Health Division HealthSpace USA Inc www.arlingtonva.us Performance Center www.waukeshacounty.gov/ www.healthspace.com www.buildingperformancecenter.org environmental_health Association of Environmental Hedgerow Software Ltd. Health Academic Programs Otter Tail County Public Health Wegmans Food & Pharmacy, Inc. www.hedgerowsoftware.com www.aehap.org www.co.ottertail.mn.us/494/Public- www.wegmans.com Hoot Systems, LLC Health Winn-Dixie Stores Cabell-Huntington Health http://hootsystems.com www.winn-dixie.com Department Paster Training, Inc. www.cabellhealth.org Industrial Test Systems, Inc. www.pastertraining.com www.sensafe.com Educational Members Chemstar Corporation Polk County Public Works Baylor University www.chemstarcorp.com Jackson County Environmental www.polkcountyiowa.gov/ Health publicworks www.baylor.edu Chester County Health www.jacksongov.org/442/ QuanTEM Food Safety East Tennessee State University, Department Environmental-Health-Division Department of Environmental www.chesco.org/health Laboratories Jefferson County Public Health www.quantemfood.com Health City of St. Louis Department of www.etsu.edu (Colorado) Seattle & King County Public Health http://jeffco.us/public-health Health Illinois State University, www.stlouis-mo.gov/government/ Environmental Health Program Kanawha-Charleston Health www.kingcounty.gov/healthservices/ departments/health www.ilstu.edu Department health.aspx Colorado Department of Public http://kchdwv.org Seminole Tribe of Florida Michigan State University Health and Environment, Division Extension Kenosha County Division of www.semtribe.com of Environmental Health and www.msue.anr.msu.edu Health Sonoma County Permit Sustainability, DPU Michigan State University, Online www.co.kenosha.wi.us/297/ and Resource Management www.colorado.gov/cdphe Master of Science in Food Safety Health-Services Department, Well and Septic Denver Department of www.online.foodsafety.msu.edu LaMotte Company Division Environmental Health www.lamotte.com www.sonoma-county.org/prmd/ University of Washington, www.denvergov.org/DEH divpages/wellsepdiv.htm Department of Environmental & Lenawee County Health Digital Health Department, Inc. Occupational Health Sciences Department Southwest District Health www.dhdinspections.com www.deohs.washington.edu www.lenaweehealthdepartment.org Department University of Wisconsin– DuPage County Health www.swdh.org Maricopa County Oshkosh, Lifelong Learning & visitanaheim.org Department Starbucks Coffee Company Environmental Services Community Engagement THE DATE SAVE www.dupagehealth.org www.starbucks.com www.maricopa.gov/631/ www.uwosh.edu/llce Ecobond Lead Defender Environmental-Services StateFoodSafety.com University of Wisconsin–Stout, www.ecobondlbp.com Multnomah County www.statefoodsafety.com College of Science, Technology, Ecolab Environmental Health Stater Brothers Market Engineering, and Mathematics www.ecolab.com https://multco.us/health www.staterbros.com www.uwstout.edu NEHA 2018 AEC • neha.org/aec

Grand Plaza, photoGrand courtsey of July/August 2017 • Journal of Environmental Health 47

JEH7-8.17_PRINT.indd 47 6/15/17 3:29 PM 2018_Save the Date_AEC.indd 1 6/12/17 1:21 PM updated from ﬁnal 6.17

YOUR ASSOCIATION SPECIAL LISTING

Arizona—Steve Wille, Maricopa County Massachusetts—Leon Bethune, Director, Environmental Services Dept., Phoenix, AZ. Boston Public Health Commission, West The board of directors includes NEHA’s nation- [email protected] Roxbury, MA. [email protected] ally elected officers and regional vice-presidents. Arkansas—Jeff Jackson, Camden, AR. Affiliate presidents (or appointed representatives) [email protected] Michigan—Sara Simmonds, MPA, REHS/RS, Grand Rapids, MI. comprise the Affiliate Presidents Council. Tech- Business & Industry—Shelly [email protected] Wallingford, MS, REHS, Retail Quality nical advisors, the executive director, and all past Assurance Manager, Starbucks, Denver, CO. Minnesota—Nicole Hedeen, presidents of the association are ex-officio council [email protected] Epidemiologist, Minnesota Dept. of Health, Adam London, White Bear Lake, MN. MPA, RS, DAAS California—Ric Encarnacion, REHS, [email protected] members. This list is current as of press time. President MPH, Assistant Director, County of Monterey Environmental Health Bureau, Mississippi—Susan Bates, Mississippi Salinas CA. Dept. of Health/Webster County Health National Officers [email protected] [email protected] Dept., Pheba, MS. Iowa, Minnesota, Nebraska, North Dakota, [email protected] President—Adam London, MPA, RS, South Dakota, and Wisconsin. Colorado—Tom Butts, MSc, REHS, DAAS, Health Officer, Kent County Health Term expires 2019. Deputy Director, Tri-County Health Dept., Missouri—Kristi Ressel, KCMO Health Department, Grand Rapids, MI. Greenwood Village, CO. Dept., Kansas City, MO. [email protected] Region 5—Tom Vyles, REHS/RS, CP-FS, [email protected] [email protected] Environmental Health Manager, Town of President-Elect—Vince Radke, MPH, RS, Connecticut—Matthew Payne, REHS/RS, Flower Mound, TX. Missouri Milk, Food, and Environmental CP-FS, DAAS, CPH, Environmental Health HHS, Environmental Health Inspector, tom.vyles@flower-mound.com Health Association—Roxanne Sharp, Specialist, Atlanta, GA. Town of Manchester, Colchster, CT. Arkansas, Kansas, Louisiana, Missouri, Public Health Investigator II, Springfield/ [email protected] [email protected] New Mexico, Oklahoma, and Texas. Term Greene County Health Dept., Springfield, MO. rsharp@springfieldmo.gov First Vice-President—Priscilla Oliver, expires 2020. Florida—Michael Crea, Sarasota, FL. PhD, Life Scientist, U.S. EPA, Atlanta, GA. [email protected] Montana—Alisha Johnson, Missoula City Region 6—Lynne Madison, RS, [email protected] County Health Dept., Missoula, MT. Environmental Health Division Director, Georgia—Tamika Pridgon. [email protected] Second Vice-President—Sandra Long, Western UP Health Department, [email protected] REHS, RS, Inspection Services Supervisor, Hancock, MI. National Capital Area—Kristen Pybus, City of Plano Health Department, Plano, TX. Hawaii—John Nakashima, Sanitarian I V, [email protected] MPA, REHS/RS, CP-FS, Fairfax County [email protected] Food Safety Education Program, Hawaii Illinois, Indiana, Kentucky, Michigan, Health Dept., VA. Dept. of Health, Hilo, HI. Immediate Past-President—David E. Riggs, and Ohio. Term expires 2019. [email protected] [email protected] MS, REHS/RS, Longview, WA. Region 7—Timothy Mitchell, REHS, CP-FS, Nebraska—Ericka Sanders, Nebraska [email protected] Idaho—Tyler Fortunati, Idaho Dept. of CQA Technical Coordinator, Publix Super Dept. of Agriculture, O’Neill, NE. Environmental Quality, Meridian, ID. NEHA Executive Director—David Markets, Inc., Lakeland, FL. [email protected] [email protected] Dyjack, DrPH, CIH, (nonvoting [email protected] Nevada—Erin Cavin, REHS, ex-officio member of the board of Alabama, Florida, Georgia, Mississippi, Illinois—David Banaszynski, Environmental Health Specialist II, directors), Denver, CO. North Carolina, South Carolina, and Environmental Health Officer, Hoffman Southern Nevada Health District, Las [email protected] Tennessee. Term expires 2020. Estates, IL. Vegas, N V. [email protected] Regional Vice-Presidents Region 8—LCDR James Speckhart, MS, [email protected] USPHS, Health and Safety Officer, FDA, Indiana—Patty Nocek, REHS/RS, Region 1—Matthew Reighter, MPH, New Jersey—Paschal Nwako, MPH, PhD, CDRH-Health and Safety Office, Silver CP-FS, La Porte County Health Dept., REHS, CP-FS, Retail Quality Assurance CHES, DAAS, Health Officer, Camden Spring, MD. La Porte, IN. Manager, Starbucks Coffee Company, County Health Dept., Blackwood, NJ. [email protected] [email protected] Seattle, WA. [email protected] Delaware, Maryland, Pennsylvania, Virginia, [email protected] Iowa—Michelle Clausen Rosendahl, Washington, DC, West Virginia, and New Mexico—Cecelia Garcia, MS, CP-FS, Alaska, Idaho, Oregon, and Washington. MPH, REHS, Director of Environmental members of the U.S. armed forces residing Environmental Health Specialist, City of Term expires 2020. Health, Siouxland District Health Dept., outside of the U.S. Term expires 2018. Albuquerque Environmental Health Dept., Sioux City, IA. Region 2—Keith Allen, MPA, REHS, DAAS, Albuquerque, NM. Region 9—Larry Ramdin, REHS, CP-FS, [email protected] Director, City of Vernon Dept. of Health & [email protected] HHS, Health Agent, Salem Board of Health, Environmental Control, Vernon, CA. Jamaica—Rowan Stephens, Salem, MA. New York—Contact Region 9 Vice- [email protected] St. Catherine, Jamaica. [email protected] President Larry Ramdin. Arizona, California, Hawaii, and Nevada. [email protected] Term expires 2018. Connecticut, Maine, Massachusetts, New [email protected] Hampshire, New Jersey, New York, Rhode Kansas—Guy Crabill, Lawrence, KS. Region 3—Roy Kroeger, REHS, Island, and Vermont. Term expires 2019. [email protected] North Carolina—Stacey Robbins, Environmental Health Supervisor, Cheyenne/ Brevard, NC. Laramie County Health Department, Kentucky—Don Jacobs, Three River [email protected] Cheyenne, WY. Affiliate Presidents District Health Dept., Fulmouth, KY. [email protected] North Dakota—Grant Larson, Fargo Cass Alabama—Stacy Williamson, MSM, [email protected] Colorado, Montana, Utah, Wyoming, and Public Health, Fargo, ND. REHS, Public Health Environmental members residing outside of the U.S. Louisiana—Bill Schramm, Louisiana [email protected] Supervisor, Covington County Health Dept., (except members of the U.S. armed forces). Dept. of Environmental Quality, Baton Red Level, AL. Northern New England Environmental Term expires 2018. Rouge, LA. [email protected] [email protected] Health Association—Brian Lockard, Region 4—Sharon Smith, REHS/RS, Health Officer, Town of Salem Health Dept., Sanitarian Supervisor, Minnesota Alaska—John Walker, Soldotna, AK. Maryland—James Lewis, Westminster, MD. Salem, NH. Department of Health, Underwood, MN. [email protected] [email protected] [email protected]

48 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 48 6/15/17 3:29 PM YOUR ASSOCIATION

Ohio—Chad Brown, RS, REHS, MPH, Davis Strategic Consulting, LLC. Institutions—Robert W. Powitz, Vanessa DeArman, Project Coordinator, Licking County Health Dept., Newark, OH. [email protected] MPH, PhD, RS, CP-FS, R.W. Powitz Program and Partnership Development [email protected] & Associates, PC. (PPD), ext. 311, [email protected] Aquatic Health/Recreational [email protected] Oklahoma—James Splawn, RPS, RPES, Health—CDR Jasen Kunz, MPH, Kristie Denbrock, Education Coordinator, Sanitarian, Tulsa City-County Health REHS, USPHS, CDC/NCEH. International Environmental ext. 313, [email protected] Dept., Tulsa, OK. [email protected] Health—Sylvanus Thompson, David Dyjack, Executive Director, ext. [email protected] PhD, CPHI(C), Toronto Public 301, [email protected] Children’s Environmental Health— Health. Oregon—William Emminger, REHS/RS, Anna Jeng, MS, ScD, Old Dominion [email protected] Santiago Ezcurra, Media Production Corvallis, OR. University. Specialist, NEHA EZ, ext. 342, [email protected] [email protected] Land Use Planning and Design— [email protected] Robert Washam, MPH, RS. Past President—Bob Custard, REHS, Climate Change—Leon Vinci, [email protected] Eric Fife, Learning Media Manager, CP-FS, Lovettsville, VA. DHA, RS. NEHA EZ, ext. 344, [email protected] [email protected] [email protected] Occupational Health/Safety— Tracy Zontek, PhD, Western Caro- Soni Fink, Strategic Sales Coordinator, Rhode Island—Dottie LeBeau, CP-FS, Drinking Water/Environmental lina University. ext. 314, [email protected] Food Safety Consultant and Educator, Water Quality—Craig Gilbertson, [email protected] Dottie LeBeau Group, Hope, RI. Minnesota Dept. of Health. Nancy Finney, Technical Editor, NEHA [email protected] [email protected] Onsite Wastewater—Joelle Wirth, EZ, ext. 326, [email protected] RS, Environmental Quality Division, South Carolina—Melissa Tyler, Emergency Preparedness and Michael Gallagher, Operations and Coconino County Health Dept. Environmental Health Manager II, Response—Marcy Barnett, MA, Logistics Planner, NEHA EZ, ext. 343, [email protected] SCDHEC, Cope, SC. MS, REHS, California Dept. of [email protected] [email protected] Public Health, Center for Environ- Onsite Wastewater—Denise TJay Gerber, Credentialing Coordinator, mental Health. Wright, Indiana State Dept. of South Dakota—John Osburn, Pierre, SD. ext. 328, [email protected] [email protected] [email protected] Health. Emergency Preparedness and [email protected] Arwa Hurley, Website and Digital Media Tennessee—Eric L. Coffey, Specialist, ext. 327, [email protected] Chattanooga, TN. Response—Martin Kalis, CDC. Radiation/Radon—Bob Uhrik, [email protected] [email protected] South Brunswick Township. Faye Koeltzow, Business Analyst, ext. [email protected] 302, [email protected] Texas—Victor Baldovinos, Food (including Safety and Environmental Health Director, Defense)—Eric Bradley, MPH, Risk Assessment—Jason Marion, Elizabeth Landeen, Associate Director, City of South Padre Island, TX. REHS, CP-FS, DAAS, Scott County PhD, Eastern Kentucky University. PPD, (702) 802-3924, [email protected] [email protected] Health Dept. [email protected] [email protected] Matt Lieber, Database Administrator, Uniformed Services—CDR Katherine Schools—Stephan Ruckman, ext. 325, [email protected] Hubbard, MPH, REHS, Senior Food (including Safety and Worthington City Schools. Bobby Medina, Credentialing Dept. Institutional Environmental Health Defense)—John Marcello, CP-FS, [email protected] Customer Service Coordinator, ext. 310, Consultant, Alaska Native Tribal Health REHS, FDA. [email protected] Consortium, Anchorage, AK. [email protected] Sustainability—Tim Murphy, PhD, [email protected] REHS/RS, DAAS, The University General Environmental Health— Marissa Mills, Human Resources of Findlay. Tara Gurge, Needham Health Dept. Manager, ext. 304, [email protected] Utah—Phil Bondurant, MPH, Director murphy@ﬁndlay.edu of Environmental Health, Summit County [email protected] Eileen Neison, Credentialing Specialist, Health Dept., Heber City, NV. Vector Control/Zoonotic Disease General Environmental Health— ext. 339, [email protected] [email protected] Control—Steven Ault, PAHO/WHO ML Tanner, HHS. (retired). Carol Newlin, Credentialing Specialist, [email protected] Virginia—David Fridley, Environmental [email protected] ext. 337, [email protected] Health Supervisor, Virginia Dept. of Health, Hazardous Materials/Toxic Sub- Lancaster, VA. Vector Control/Zoonotic Disease Solly Poprish, CDC Public Health stances—Crispin Pierce, PhD, [email protected] Control—Zia Siddiqi, PhD, BCE, Associate Program Intern, ext. 335, University of Wisconsin-Eau Claire. Orkin/Rollins Pest Control. [email protected] Washington—Michael Baker, MS, PhD, [email protected] [email protected] Dept. of Environmental Health Director, Barry Porter, Financial Coordinator, ext. Healthy Communities/Built Envi- Whitman County Public Health, Pullman, WA. 308, [email protected] ronment—Kari Sasportas, MSW, Workforce Development, Manage- [email protected] MPH, REHS/RS, Cambridge Public ment, and Leadership—George Kristen Ruby-Cisneros, Managing Editor, Nakamura, MPA, REHS, RS, West Virginia—Brad Cochran, Health Dept. Journal of Environmental Health, ext. 341, CP-FS, DAAS, Nakamura Leasing. Charleston, WV. [email protected] [email protected] [email protected] [email protected] Healthy Homes and Housing— Rachel Sausser, Member Services/ Wisconsin—Sonja Dimitrijevic, Dept. Judeth Luong, City of Long Beach NEHA Staff: Accounts Receivable, ext. 300, of Agriculture, Trade, and Consumer Health Dept. [email protected] Protection, WI. [email protected] (303) 756-9090 Christl Tate, Program Manager, PPD, [email protected]. Seth Arends, Graphic Artist, NEHA Industry—Nicole Grisham, - ext. 305, [email protected] Univer Entrepreneurial Zone (EZ), ext. 318, Wyoming—Tiffany Gaertner, REHS, sity of Colorado. [email protected] Sharon Unkart, Instructional Designer, CP-FS, EHS II, Cheyenne-Laramie County [email protected] NEHA EZ, ext. 317, [email protected] Health Dept., Cheyenne, WY. Jonna Ashley, Association Membership Informatics and Technology—Dar- [email protected] Manager, ext. 336, [email protected] Gail Vail, Director, Finance, ext. 309, ryl Booth, MPA, Accela. [email protected] [email protected] Rance Baker, Program Administrator, Technical Advisors NEHA EZ, ext. 306, [email protected] Sandra Whitehead, Director, PPD, Injury Prevention—Alan Della- Air Quality—Vacant [email protected] penna, RS, North Carolina Division Trisha Bramwell, Sales and Training Aquatic Health/Recreational of Public Health. Support, NEHA EZ, ext. 340, Joanne Zurcher, Director, Government Health—Tracynda Davis, MPH, [email protected] [email protected] Affairs, [email protected]

July/August 2017 • Journal of Environmental Health 49

JEH7-8.17_PRINT.indd 49 6/15/17 3:29 PM YOUR ASSOCIATION

ATributeto Our Peer Reviewers, 2016–2017 he Journal of Environmental Health thanks and honors the individuals listed below whose contributions as peer reviewers are T paramount to the Journal’s efforts to advance, educate, and promote the science and profession of environmental health. We sincerely appreciate their hard work, devotion to the environmental health profession, and willingness to share their wealth of knowledge and expertise.

Becky Nancy Achieng Aloo, MSc Eric Bradley, MPH, REHS, Paulomi Das, MSc, PhD Matthew Gribble Eldoret, Kenya CP-FS, DAAS Kalyani, India Baltimore, MD Davenport, IL Anna Marie Aragon, MSIR, Tracynda Davis, MPH Yi Guo, MSPH, PhD MAEd, CPS, ASP, REHS Freda W. Bredy, REHS, PMP Colorado Springs, CO Gainesville, FL APO, AE Alexandria, VA Royal DeLegge, PhD, LEHS, RS John J. Guzewich, MPH, RS Sushrut Arora, MVSc, PhD David Breeding, PhD, RS, CSP Murray, UT Albany, NY Houston, TX College Station, TX James D. Dingman, MS, REHS, Eric S. Hall, MA, MCE Gholamreza Asadollahfardi, Matthew C. Brim, MS DLAAS Durham, NC MS, PhD Belton, TX Plano, TX Tehran, Iran Daikwon Han, PhD Gary Brown, DrPH, CIH, RS Maria Alzira Primenta Dinis, PhD College Station, TX Erik Balster, MPH, REHS, RS Richmond, KY Porto, Portugal Eaton, OH Xuesong Han, PhD Rosemary M. Caron, MPH, PhD Zachary Ehrlich, MS, REHS Atlanta, GA David Banaszynski, REHS, CP-FS Durham, NH West Orange, NJ Hoffman Estates, IL Justin E. Harbison, PhD Byron D. Chaves-Elizondo, MS Robert Emery, DrPH, CHP, CIH, Maywood, IL Brad H. Baugh, PhD, RN, Lubbock, TX CSP, RBP, CHMM, CPP, ARM REHS/RS, RPIH Houston, TX Francis Charles Hart, PhD, CIH, Nine Mile Falls, WA Jiangang Chen, PhD CSP, RS Knoxville, TN Major Jason Finley, MS, DAAS, Kent, OH Alan Becker, MPH, PhD REHS, RS, CHMM Tallahassee, FL Valerie M. Cohen, MPH, REHS Louisville, KY Muhammad Zaffar Hashmi, MSc, Las Vegas, NV MPhil, PhD C. Thomas Bell, PhD, RS Thomas R. Gonzales, MPH, REHS Islamabad, Pakistan Lebanon, OH James Couch, MS, CIH, CSP, Colorado Springs, CO REHS/RS Jerry Hatch, CP-FS, CEHT, BCE Mitchell Berger, MPH Cincinnati, OH Patrick Goodman, PhD St. Petersburg, FL Exton, PA Dublin, Ireland Chris J. Coutts, MPH, PhD Timothy N. Hatch, MPH, REHS Dean Bodager, MPA, RS, DAAS Tallahassee, FL Harry E. Grenawitzke, Jr., MPH, Montgomery, AL Orlando, FL RS, DAAS CDR Miguel Cruz, MPH Monroe, MI Michelle Homan, PhD Craig Bowe, PhD Atlanta, GA Erie, PA Freeport, Bahamas

50 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 50 6/15/17 3:29 PM YOUR ASSOCIATION

Major Joseph J. Hout, PhD, CIH, Xuyang Liu, PhD Amy Roberts, RN John A. Steward, MPH, REHS CSP, REHS, DAAS St. Louis, MO Kansas City, MO Atlanta, GA Lytle, TX Ting Lu, PhD CDR Luis O. Rodriguez, MS, Major Michael C. Story, MPH, Jin Huang, PhD Cincinnati, OH REHS/RS, CP-FS MBA, REHS/RS Athens, OH Fort Lauderdale, FL Fort Sam Houston, TX Yuan Lu, PhD Li Huang, PhD Houston, TX Paul Rosile, MPH, PhD, RS Roman Tandlich, PhD Albany, NY Richmond, KY Grahamstown, South Africa Ming Luo, PhD Elizabeth Irvin-Barnwell, PhD Rensselaer, NY Jeff Rubin, PhD, CEM, NREMT-B M.L. Tanner, HHS Atlanta, GA Tigard, OR Swansea, SC James C. Mack, MPA, REHS James D. Johnston, PhD, CIH Madison, WI Kenny D. Runkle, DPA, LEHP, Sylvanus Thompson, PhD, Provo, UT REHS CPHI(C) Lois Maisel, RN, CP-FS Springﬁeld, IL Toronto, Canada Kimball E. Jones, MSPH, RS-E Fairfax, VA Lake Forest Park, WA Ben Ryan, MPH Lawrence J. Tirri, PhD Ephraim Massawe, PhD Queensland, Australia Las Vegas, NV Misty Joy, MPH, REHS Hammond, LA Cumberland, MD Ratul Saha, MSc, MS, PhD James Trout Ruth McDermott-Levy, MPH, New Brunswick, NJ St. Louis, MO Gregory D. Kearney, MPH, PhD, RN DrPH, RS Villanova, PA Michéle Samarya-Timm, MA, Rong Wang, PhD Greenville, NC HO, MCHES, REHS, DAAS New Haven, CT Edward Mc Keown, MS, PhD Franklin Park, NJ Igor Koturbash, PhD, MD Flagstaff, AZ Yi Wang, PhD Little Rock, AR Fatih Sekercioglu, MSc, MBA, Indianapolis, IN Stuart Mitchell, MPH, PhD, BCE CIPHI(C) Keith L. Krinn, MA, RS, Des Moines, IA London, Canada Chris J. Wiant, MPH, PhD DAAS, CPHA Denver, CO Columbus, OH G. Poyya Moli, PhD CAPT Sarath Seneviratne, CIH, Pudacherry, India CSP, CBSP, CHMM, RBT, CET, Sacoby Wilson, MS, PhD Sharron LaFollette, PhD REHS, MS, DAAS College Park, MD Michele M. Monti, MS, MPH Springﬁeld, IL Bethesda, MD Atlanta, GA Felix I. Zemel, MCP, MPH, CEHT, John Lange Behzad Shahmoradi, PhD HHS, REHS/RS, CPO Vinayak K. Nahar, MS, MD Pittsburgh, PA Sanandaj, Iran Needham, MA Oxford, MS Madeleine LaRue Derek G. Shendell, MPH, DEnv Tyler Zerwekh, MPH, DrPH, REHS Asia Neelam, MSc Chapel Hill, NC Piscataway, NJ Memphis, TN Karachi, Pakistan Grace Lasker, PhD, CN Samendra Sherchan, PhD Tao Zhan, PhD Priscilla Oliver, MPA, PhD Kirkland, WA New Orleans, LA Elk Grove, CA Atlanta, GA Scott T. LeRoy, MPH, MS, Kevin Sherman, PhD, PE, DWRE Kai Zhang, MS, PhD LCDR Stephen M. Perrine, MS, REHS/RS Crampbellsburg, KY Buffalo, NY New Milford, CT REHS/RS, CP-FS Washington, DC Jo Anna M. Shimek, MS, PhD, Yougui Zheng, PhD Courtney D. Lewis, MS CIH, CSP Houston, TX Eric Pessell, REHS Odessa, TX Bloomington, IN Grand Rapids, MI Zheng Zhou, MS, PhD Dingsheng Li Ivy Shiue, MSc, PhD Minneapolis, MN David S. Peterson, MBA, MPA, Ann Arbor, MI Newcastle upon Tyne, England RS, DAAS Jinqiu Zhu, MS, PhD Zhanbei Liang, PhD Edmonds, WA Zia Siddiqi, PhD, BCE Buffalo, NY Ada, OK Atlanta, GA Robert W. Powitz, MPH, PhD, Chuck Lichon, MPH, RS RS, DLAAS Satheesh Sivasubramani, PhD Linwood, MI Old Saybrook, CT Galveston, TX

Maureen Y. Lichtveld, MPH, MD Reginald Quansah, PhD David A. Sterling, PhD, CIH New Orleans, LA Oulu, Finland Fort Worth, TX

July/August 2017 • Journal of Environmental Health 51

JEH7-8.17_PRINT.indd 51 6/15/17 3:29 PM YOUR ASSOCIATION NEHA NEWS

Starting Off With Impact: The NEHA 2017 AEC tific evaluation of how laws can affect health. By partnering with Keynote and Opening Session CDC’s Public Health Law Program, NEHA exposed its local envi- By Kristie Denbrock ([email protected]) ronmental health member base to this relevant, yet mysterious, Don’t miss the opportunity to hear Representative Brenda L. Law- topic. Using legal epidemiology principles and methods allows rence (D-Michigan) deliver the NEHA 2017 Annual Educational environmental health professionals to assess their own local laws Conference (AEC) & Exhibition Keynote on Monday, July 10 in and policies and use that information for evaluation and future Grand Rapids, Michigan. Representative Lawrence, a champion of program planning. environmental health, recently reintroduced the Environmental The first webinar held in May focused on a broad introduction Health Workforce Act bill on April 5, 2017. The bill ensures that to legal epidemiology and described how it could be used as a tool there is a consistent set of guidelines and standards for training and when advancing from data to policy. The second webinar brought education of environmental health professionals across the nation. a technical focus to the series and provided applied legal epidemi- “Every American deserves the right to safe drinking water, clean ology examples. Both webinars, presentation slides, and presenter air to breathe, and a healthy community to raise their children,” information are available for free on NEHA’s website at www.neha. stated Representative Lawrence. “This legislation will provide a org/legal-epidemiology. roadmap to rebuilding the local public health workforce, restore You can register for the third and final webinar of the series, A our faith in government, and renew our commitment to our chil- Tool for Addressing Health in All Policies, being held on August dren’s quality of life.” 16 at 1:00 p.m. EDT. NEHA’s Dr. Sandra Whitehead will be speak- Following Representative Lawrence’s keynote presentation will ing about Health in All Policies implementation at the local level. be our Opening Session—Aiming for Equity—with Renée Branch Learn more about legal epidemiology and register for the webinar Canady, MPA, PhD, chief executive officer of the Michigan Public at www.neha.org/legal-epidemiology. Health Institute, leading a panel of experts to discuss present day Reference issues in environmental justice. Burris, S., Ashe, M., Levin, D., Penn, M., & Larkin, M. (2016). A Joining Dr. Canady on the panel will be Dr. Pamela Pugh, public transdisciplinary approach to public health law: The emerging health advisor for the City of Flint; Dr. Marcus Cheatham, health practice of legal epidemiology. Annual Review of Public Health, officer for the Mid-Michigan District Health Department; and Pon- 37, 135–148. Retrieved from http://www.annualreviews.org/doi/ sella Hardaway, executive director of Detroit’s Metropolitan Orga- abs/10.1146/annurev-publhealth-032315-021841 nizing Strategy Enabling Strength (MOSES) organization. This interactive panel will focus on fair treatment and oppor- NEHA Staff Profile tunities for individuals to participate in discussions and to con- As part of tradition, NEHA features new staff members in the Jour- tribute to activities that can affect environmental health in their nal around the time of their one-year anniversary. These profiles communities give you an opportunity to get to know the NEHA staff better and Let your voice be heard in the fair environmental health treat- to learn more about the great programs and activities going on in ment of all people regardless of race, color, national origin, or your association. This month we are pleased to introduce you to income—join us for our exciting 2017 AEC Keynote and Opening one NEHA staff member. Contact information for all NEHA staff Session. More information about the 2017 AEC can be found at can be found on page 49. www.neha.org/aec. Seth Arends I graduated from the Metropolitan State NEHA’s New Legal Epidemiology Webinar Series University of Denver in 2014 earning By Ellen Cornelius ([email protected]) a bachelor of fine arts degree with an Laws and policies are essential to environmental health issues. In emphasis in communication design. My fact, one can make a case that every one of the Centers for Disease career began at a small design firm, Ellen Control and Prevention’s (CDC) greatest public health achieve- Bruss Design, located here in Denver. It ments of the 20th century can be attributed in part to legal inter- was there that I began to translate my ventions (Burris, Ashe, Levin, Penn, & Larkin, 2016). Over this abilities into a professional atmosphere. summer, NEHA has made the somewhat elusive and politically That was the first time in my life where charged topic of policy and health accessible to its local environ- I was compensated while performing mental health practitioners by hosting parts 1 and 2 of the Legal tasks I’m truly passionate about. It was an unfamiliar, liberating, Epidemiology Webinar Series. and addictive feeling that forever changed my professional life. Legal epidemiology is an emerging field that blends the prac- After getting some wind under my wings, I began to attract more tice of developing and implementing health laws with the scien- freelance clients for both print and web design. For 18 months, I

52 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 52 6/15/17 3:29 PM YOUR ASSOCIATION NEHA NEWS

created nearly any kind of branding collateral imaginable, from tional design positions—any destination I felt I could add value chap stick labels, logos, and commercial brochures to full-scale, and enjoy the work. In a series of fortunate events, I was eventu- interactive web destinations. But as freelancing gradually became ally hired by NEHA as its graphic designer. a fi nancial feast or famine situation each month, I began to search Working at NEHA has been a dream realized. I get my feet wet for a more secure position. working in many design facets such as illustration, infographics, As an artist, I was satisfying my hunger for ideas, but not my advertising, typography, photography, interactive design, and even hunger for meaning. In a perfect world, I could develop fantastic animation, which means that the work is engaging. Considering work that could contribute toward positive change in the world the political climate, the public is in dire need of organizations and in my own community. I not only wanted to create but also such as NEHA, and being a part of that is rewarding. NEHA has wanted to make a difference and feel good about the day’s work. provided a platform for me to development as a designer and the I applied to various nonprofi t organizations and specifi c educa- future is bright with many exciting projects on the horizon.

NEHA offers different membership options to suit your professional needs. Did You From students and those just starting the profession all the way up to those retiring, NEHA has a membership for everyone. And you can select multiple Know? year options and how you want to receive the Journal. Visit www.neha.org/ membership-communities/join? for more information. DirecTalk continued from page 54 TABLE 1 different things about what we do. How could they not? NEHA member Ken Runkle Emerged or Emerging Environmental Health Challenges recently penned a blog on LinkedIn titled “What’s Wrong With Environmental Health?” Dr. Tom Burke: Wicked National Josh Dugas and Steve Van Stockum: I encourage you to read his short article. Ken Environmental Health Problems California Environmental Health Challenges describes how many of us don’t prioritize Fracking Assisted living facilities using the term environmental health as our Infectious diseases (Ebola, Legionella) Sustainability primary skill set, even among ourselves. Pesticides Day camps NEHA has retained an ad agency, 3 Adver- tising (www.3advertising.com), to assist us in Perfl uorooctanoic acid (PFOA) Graywater/black water thinking through these and other related issues Environmental justice Marijuana edibles as we aim to promote, protect, and enhance the Air pollution Home restaurants profession. We hope their preliminary efforts Water resources Groundwater will be complete by the time of our 2017 Annual Agriculture Organics management (waste food) Educational Conference (AEC) & Exhibition, Climate Climate and that we might possess the intellectual embryo that will give rise to new approaches Wastewater infrastructure Septic systems to consistently communicate among ourselves and the world around us. nation. NEHA staff has assembled thought I look forward to seeing you there, in part If you want to weigh-in or learn more leaders, influencers, and subject matter to discuss how we might begin the journey about the state of the profession, I encourage experts in Grand Rapids, a town known of reassembling the fragmented state of the you to attend our 2017 AEC in Grand Rap- for its walkability, accessibility, and family- environmental health profession. ids, Michigan, on July 10–13. The theme this friendly environment. Our opening and clos- year—Local Solutions. National Infl uence— ing panel sessions will showcase fresh faces will explore the profoundly local nature of and have been designed to address some of [email protected] the profession and how we might use our col- the most important issues of our time: envi- Twitter: @DTDyjack lective infl uence to improve the health of the ronmental health equity and sustainability.

July/August 2017 • Journal of Environmental Health 53

JEH7-8.17_PRINT.indd 53 6/15/17 3:29 PM 1 table, 1 ﬁ gure

YOUR ASSOCIATION

 DirecTalk MUSINGS FROM THE 10TH FLOOR

Professional (dis) Association

David Dyjack, DrPH, CIH

ay marked my two-year anniver- increasingly need attention. For the record, I sary at NEHA’s helm. It’s been an also agree with Josh and Steve and their list. M amazing 24-month sojourn. Our FIGURE 1 Upon careful examination and comparisons association developments and progress are Select Federal Players in of the two lists, you’ll observe overlap, maybe well described in our Annual Report avail- the Environmental Health even a signifi cant portion, though the over- able at www.neha.org. Therefore, I’d rather Landscape lap is described using dissimilar terminology. use this column to advance thought around There is also a large disconnect between the a more sobering and provocative issue, my content of the two lists. Both of my observa- perception of the fragmented state of the en- tions are troubling. Where the two lists align, vironmental health profession. they use different nomenclature to describe Figure 1 is derived from one of my stock the challenges at hand. On the other end of the PowerPoint presentations. The agency names spectrum, there seems to be a chasm between are not as important as what they symbolize the priorities articulated by those inside the in aggregate—a profession that is a classic beltway and those reported by local practitio- example of the tragedy of the commons. There ners. This issue is a symptom of a larger prob- are at least 16 federal agencies with a bite of lem that we need to overcome—simplicity in the environmental health apple. Collabora- describing priorities and messaging within tion and cooperation among the various play- and outside the profession. I trust you see the ers is intermittent at best and often occur as a merit in my observations. function of the latest crisis that dominates the In Words that Work: It’s Not What You Say, headlines. Think Flint, Zika, or fracking for It’s What People Hear, Dr. Frank Luntz sug- recent examples of agency shotgun weddings, gests that consistency matters in all things often courtesy of public outrage. related to communications. My friends, our Professional and subject matter heteroge- next cosmic journey is to harmonize our nicity is also a contributing factor to the state messaging and priorities, and to ensure they of confusion regarding who we are and what other things, 1) socially complex, 2) diffi cult are packaged and presented in a manner that we do. Please peruse Table 1 (see page 53). to defi ne, 3) complex on spatial and temporal resonate with society’s values and beliefs. The left column presents content provided scales, and 4) affected by many interacting fac- Let me be clear: federal, state, local, private by Dr. Tom Burke, the widely respected and tors. I happen to agree with Tom and his list. sector, and academic environmental health admired Johns Hopkins University professor. I happen to also agree with my colleagues professionals should use similar words to I have taken some liberties with the material from California and their list. Please digest describe similar conditions, and we should he described at a recent National Academies the right column of Table 1, which was pre- generally agree on national priorities, taking of Sciences, Engineering, and Medicine work- sented by my friends Josh Dugas and Steve into consideration some local variation. shop in Washington, DC. At that meeting, Dr. Van Stockum at a recent California Environ- Second, to be effective, we need to take Burke characterized his list as wicked envi- mental Health Association meeting in Ana- into consider what people hear, not what ronmental health problems that desperately heim. The Californians described emerging we are saying. I suggest society hears wildly need attention. These challenges are, among professional issues in California that will continued on page 53

54 Volume 80 • Number 1

JEH7-8.17_PRINT.indd 54 6/15/17 3:29 PM ■ Easy ■ Powerful ■ Affordable Environmental Health Software

Visit us at the NEHA AEC conference July 10-13 in Grand Rapids, MI BOOTH #101

949.480.5500 | inspect2go.com [email protected]

JEH7-8.17_PRINT.indd 55 6/15/17 3:29 PM Responsive Data Management for Public & Environmental Health

Every day, hundreds of Inspectors in Public Health and Government Agencies - Inspectors like Angie - use our Information Systems to minimize health risks and protect their public.

HS CLOUD HSCloud. Simple,

Effective Data

fg fg Management Customized to suit your organization’s every need. HS HS TOUCH TOUCH

HSTouch lets you conduct paperless ﬁeld inspections from any place, at any time.

When Angie makes a call, her work is available to the department and the public within minutes. She always has the information she needs for maximum productivity and accuracy. Facilities are never missed and high-hazard establishment inspections are never late.

Call us today:

1.866.860.4224. Ext. 3366=DEMO HealthSpace.com

JEH7-8.17_PRINT.indd 56 6/15/17 3:29 PM E-JOURNAL BONUS ARTICLE

 INTERNATIONAL PERSPECTIVES

Kwangtae Ha Characteristics of Airborne Sooknye Chung Suhyun Lee Mihae Kang Asbestos Concentrations in Institute of Public Health and Environment Korean Preschools Seoul Metropolitan Government Research Gayeon Kim Department of Public Health Dankook University Seungsung Yoo Abstract The objective of this study is to evaluate the possi- Soomi Eo Kweon Jung bility or extent of asbestos pollution in small-scale preschools, which are Changkyu Kim asbestos-containing buildings (ACBs), and to provide management plans Institute of Public Health and Environment for them. Korea is legally managing preschools with a total ground area of Seoul Metropolitan 430 m2 or above as ACBs, but is not legally regulating preschools smaller Government Research than 430 m2 (small-scale preschools) that account for 90.4% of all preschools. Thus, this study selected 46 small-scale preschools in Seoul, collected airborne samples at 91 points, and analyzed the samples with phase education programs on asbestos management. Korea has included an item on asbestos in contrast microscopy and transmission electron microscopy. The result by the Indoor Air Quality Control Act for public the ISO 10312 method satisfied the Korean Indoor Air Quality Control Act facilities such as libraries, museums, hospitals, (≤0.01 fibers/cc) (International Organization for Standardization, 1995). preschools, passenger terminals, and subway The analysis result by the Asbestos Hazard Emergency Response Act method stations. Asbestos in small-scale preschools 2 was lower than the filter background level. There is a method to remove or smaller than 430 m , however, is not legally managed. Out of 43,646 preschools, 39,440 eliminate asbestos, but this method increases the risk of exposure to air- (90.4%) were small-scale preschools in Korea borne asbestos, so it seems better to effectively maintain and manage the as of July 2014, which indicates that many buildings of small-scale preschools to prevent airborne asbestos. preschools are excluded from asbestos management plans (Comprehensive Information Network for Asbestos Management, 2014). As Introduction materials for slates, car brake linings, fire-pre- a result of actually selecting and investigating Once thought of as a wonder mineral because vention dusting agents, pipe laggings, firefight- 100 small-scale preschools smaller than 430 of its inherent beneficial qualities that included ing garments, electric appliance insulators, and m2 in the metropolitan area (Seoul, Incheon, resistance to fire, heat, and corrosion—as well floor tiles (Paik & Lee, 1991). In particular, and Kyeonggi), an area that accounts for as being strong, durable, flexible, and inexpen- approximately 80–95% of imported asbestos half the population in our country, 8 out of sive—asbestos has now become regarded as a was used as building materials until the late the 29 schools (27%) in Seoul, 7 out of the hazardous material (International Agency for 1990s (Jeong, Cho, Park, & Lee, 2013). 20 schools (35%) in Incheon, and 15 out of Research on Cancer [IARC] Working Group, The hazards and dangers presented by the 51 schools (29%) in Kyeonggi were identi- 2012). Asbestos has been produced in Korea exposure to asbestos, including chrysotile, fied, confirming that 30 (30%) out of the 100 since the 1930s, and asbestos imports increased cause an increased likelihood of developing small-scale preschools were made of asbestos- as secondary industries rapidly developed in cancer of the lung, larynx, and ovary; meso- containing materials (Ministry of Health and the 1970s. These imports decreased from 1997 thelioma (a cancer of the pleural and perito- Welfare [Korea], 2012). when some forms of asbestos, such as crocido- neal linings); and asbestosis (fibrosis of the Childcare for Korean children is heavily lite and amosite, were prohibited (Park, Choi, lungs) (IARC, 2012). dependent on preschools as both parents Ryu, Park, & Paik, 2008). Then in 2009, after Thus, Seoul is surveying the use of asbes- are often engaged in economic activities. In the Kubota Coincidence in Japan, use, manu- tos in city-owned public buildings and car- addition, they want their children to receive facturing, distribution, and import of asbestos rying forward a project to eliminate asbestos. quality education. Moreover, children spend and asbestos-containing materials were pro- It is also actively engaged in drawing a map most of their day in indoor spaces and are hibited in Korea (Kang & Kim, 2010; Kim, of asbestos in asbestos-containing buildings thereby susceptible to the indoor air quality; 2009). In Korea, asbestos mostly was used as (ACBs), and conducting promotional and thus, parents prefer preschools with pleas-

July/August 2017 • Journal of Environmental Health • Volume 80, Number 1 E1 E-JOURNAL BONUS ARTICLE

FIGURE 1 FIGURE 2 Sampling Sites of Small-Scale Preschools at 20 Boroughs in Sampling Points in Small-Scale Seoul, Korea Preschools

Kitchen Corridor 3% 3% Lounge 4% Teachers Gangbuk (2) Room Eunpyeong (4) Nowon (2) 14%

Seongbuk (3) Jungnang (2) Others Jongno (1) 23% Dongdaemun Classroom (1) 45%

Gangseo (11) Jung (2) Seodaemun (1) Seongdong (2) Gangdong (1)

Yangcheon (2) Bathroom Yeongdeungpo Songpa (2) (1) 8%

Dongjak (2) Guro (2) Gangnam (2)

Geumcheon Samples were conducted in accordance Gwanak (1) (2) with the aceton/triacetin method and then expressed as concentrations of fibrous materials (in f/cc) at a magnification of 400 times by phase contrast microscopy (PCM) inserted into the Walton–Beckett eyepiece graticule ant facilities and perceived better indoor air often encountered by children and teachers, (Lange, 2001). Airborne fibrous materials quality. There is no clear evidence indicating as well as places where there might have been were counted as fibrous (including asbestos) that children are more at risk than adults to exposure to asbestos (Figure 2). when the fibers had a length of >5 μm and a asbestos exposure (Agency for Toxic Sub- ratio of at least 3:1 in diameter. stances and Disease Registry, 2001). Chil- Sample Collection and Analysis When the result of analyzing with PCM dren, though, can have a longer period of Method exceeded 0.01 f/cc (the Indoor Air Qual- exposure to asbestos and therefore an earlier Sampling was conducted at locations within ity Control Act criterion), we prepared the onset possibility of asbestos-related diseases. the indoor facilities. These locations were cho- remaining samples without an additional sam- Therefore, the objective of this study is to sen to minimize changes in wind or airflow ple collection, and analyzed them with trans- test the airborne asbestos concentrations in and the sampling was conducted by an air mission electron microscopy (TEM) according small-scale preschools built within ACBs in trapping method with an airflow rate of 10 L/ to the ISO 10312 method (International Orga- Seoul, and reduce the potential harm caused min to detect dust concentrations. In all, 1,210 nization for Standardization [ISO], 1995). by asbestos by providing accurate informa- L was sampled for 2 hours. A SARA-4000 Samples were analyzed at 18,500x mag- tion and an effective management plan. Asbestos Sampler was used for the sampling of nification, which were counted as asbestos airborne asbestos in preschools. A mixed cel- f/cc according to the ISO 10312 rule (ISO, Materials and Methods lulose ester membrane filter (0.8 μm pore size, 1995), while asbestos structures/cc (s/cc) 25 mm diameter) was used as the sampling fil- were counted according to the Asbestos Survey Period and Site ter. We measured samples in accordance with Hazard Emergency Response Act (AHERA) Samples were collected from a total of 91 the indoor air quality standards of “Indoor rule (U.S. Environmental Protection Agency, points in 46 separate small-scale preschools air—How to measure the concentration of 1987). Airborne asbestos concentrations of at 20 boroughs in Seoul during 9 months, asbestos dust and fiber-phase microscopy” small-scale preschools were examined by from April to December 2015, surveying air- announced by Korea ES 02303.1 (Notice of determining whether the airborne fibrous borne asbestos concentrations (Figure 1). Ministry of Environment No. 2010-24) (Min- materials from the PCM analysis results were Samples were collected from living spaces istry of Environment of Korea, 2010). actual asbestos fibers.

July/August 2017 • Journal of Environmental Health • Volume 80, Number 1 E2 E-JOURNAL BONUS ARTICLE

TABLE 1 Management State of Asbestos Materials in Small-Scale Preschools

Condition Asbestos-Containing Materials Interior Satisfactory Damaged Textile Textile and Baumlite Slate Wallpaper Paint on the Others Baumlite Walls 44 2 27 10 7 2 27 7 15

Note. The damage level, types of asbestos-containing materials, and interior status were examined by on-site visits to the preschools.

the other preschools. As a result of analysis TABLE 2 with sensitivity 0.0036 s/cc according to the AHERA method (length ≥ 0.5 μm, width > Concentrations of Airborne Fibrous Materials Detected With Phase 0.25 μm, length-to-width ratio ≥ 5:1), 0.0072 Contrast Microscopy Analysis s/cc (teachers room) and 0.0036 s/cc (classroom) of chrysotile were detected in two pre- Places # of # of Maximum Minimum Mean ± SD Criteria schools. These numbers are lower than the Samples Exceeded (f/cc) (f/cc) (f/cc) filter background level. Chrysotile, however, a Samples was not detected in any of the other pre- Teachers room 13 3 0.035 0.000 0.009 ± 0.010 Indoor Air schools (Figure 4). Classroom 41 16 0.031 0.002 0.010 ± 0.008 Quality On the other hand, even though it was Control Act Bathroom 7 3 0.026 0.006 0.012 ± 0.007 (≤0.01 f/cc) expected that airborne asbestos would be Lounge 3 2 0.022 0.004 0.013 ± 0.009 detected in the two preschools that contain Kitchen 3 0 0.003 0.002 0.003 ± 0.001 it, surprisingly, airborne asbestos was not Corridor 3 1 0.011 0.009 0.010 ± 0.001 detected in these two schools. By construc- Others 21 4 0.040 0.000 0.007 ± 0.008 tion year, 39 out of the 46 preschools (85%) Total 91 29 0.040 0.000 0.009 ± 0.008 were constructed in the 1980s and 1990s, and

Note. The concentration (f/cc) is determined by counting only fibers with length > 5 μm and a length-to-width ratio asbestos was detected in one preschool con- of ≥ 3:1. structed in the 1980s and one preschool con- aThe number of places in which concentrations of airborne fibrous materials exceeds 0.010 f/cc. structed in the 1990s by applying the AHERA method (length ≥ 0.5 μm, width > 0.25 μm, length-to-width ratio ≥ 5:1) (Table 3). Results seven spaces or rooms monitored had average concentrations of fibrous materials at 0.01 Discussion Management of Asbestos in Small- f/cc or above, which is the Indoor Air Quality We examined asbestos concentrations Scale Preschools Control Act criterion (Ministry of Environ- obtained at 91 points from 46 small-scale We selected 46 small-scale preschools in ment of Korea, 2017). Overall, the distribu- preschools that were smaller than 430 m2 in Seoul, collected samples from 91 points, tion was 0.000–0.040 f/cc (Table 2, Figure Seoul, and they all complied with the Indoor and analyzed them with PCM and TEM. We 3). Of the total 91 points, 29 points exceeded Air Quality Control Act (≥0.01 f/cc). Any found that for ACB materials in preschools, 0.010 f/cc, but we used TEM for a precise particle longer than 5 μm in length shall textiles accounted for at least 80% of the analysis, as the measured fibrous materials be defined as an asbestos fiber according to asbestos materials, and the remaining 20% cannot be assumed to be asbestos. Korean law. A particle of the minimum length was made up of baumlite and slate. Of the of 0.5 μm, however, is defined as asbestos 46 preschools, 44 of them were being man- Airborne Fibrous Materials With TEM fiber in the U.S. (AHERA method), so we aged in a satisfactory condition, while two As a result of analysis with sensitivity 0.0009 sought to detect and identify the distribution were likely to reveal the presence of airborne f/cc according to the ISO 10312 method of fibers that were less than 0.5 μm. asbestos; 34 of them had indoor wallpapers (length > 5 μm, width 0.2–3.0 μm, length- Chrysotile was found in two preschools, or paint on the walls (Table 1). to-width ratio ≥ 3:1) using TEM, 0.0018 f/cc in a teachers room and a classroom, at lower (teachers room) of chrysotile was detected than the filter background level. The prin- Airborne Fibrous Materials With PCM from one preschool, but it still complied with cipal varieties of asbestos are a serpentine PCM test results showed that four (class- the Indoor Air Quality Control Act (≥0.01 f/cc), material called chrysotile, and crocidolite, room, bathroom, lounge, corridor) out of the while chrysotile was not detected in any of amosite, anthophyllite, tremolite, and actino-

July/August 2017 • Journal of Environmental Health • Volume 80, Number 1 E3 E-JOURNAL BONUS ARTICLE

FIGURE 3 Distribution of the Airborne Concentrations of Fibrous Materials Detected With Phase Contrast Microscopy

0.040 0.040

0.035

0.031 (f/ cc ) 0.030 t ion

tr a 0.026 Indoor Air Quality Control Act Level (0.01 f/cc) 0.022 Con ce n

0.020 s es t o b s A

0.013 0.012 0.011 0.010 0.010 0.010 0.009 rborn e i 0.009 A 0.006 0.007 0.004 0.003 0.002 0.003 0.002 0.000 0.000 0.000 Teachers Room Classroom Bathroom Lounge Kitchen Corridor Others

Sample Location

lite—which are a type of dark mineral called of non-asbestos materials. The problem is that the risk be managed instead of remov- amphiboles (Mirabelli et al., 2008). All that many preschools built before 2009 are ing the asbestos (Lee & Van Orden, 2008). detected asbestos was chrysotile, which was ACBs, and therefore present a real risk of Asbestos was barely detected in this study, less than 10 μm long. Chrysotile, if smaller exposure to asbestos for inhabitants—a risk confirming that the asbestos exposure levels than 20 μm, generally can be broken down in which must be managed. are not high in preschools on a daily basis. the body, but other amphiboles are deposited In general, there are two ways to reduce The risk posed by asbestos is emerging as a on the diaphragm, causing fibrosis (Bernstein the risk from asbestos. major social issue in Korea. This issue is only et al., 2013). 1) Dismantle and remove the asbestos. Asbes- natural considering the fact that asbestos All detected chrysotile was less than 10 tos is likely to be emitted in the process of is a carcinogen that was commonly used in μm, and thus presented a low risk. Asbestos dismantling it, and the need for contain- Korea and also that there is greater interest was barely detected in small-scale preschools ment will also generate costs. When disin and awareness of matters related to health smaller than 430 m2 in Seoul, even though mantling asbestos buildings, it is necessary and safety. Excessive concerns over the risk they are ACBs. This finding is because most to establish a systematic plan and methods of exposure to asbestos, however, may create preschools naturally prevented airborne asbes- to prevent airborne asbestos. social fear and confusion. Countries such as tos by using wallpapers, paints, and silicon 2) Maintain and manage the buildings by the U.S. assume, in the managerial sense, that finishes in the interior for heat insulation. By establishing prevention methods (enclosure, asbestos poses little risk as long as it is not construction year, the preschools constructed encapsulation, repair). Airborne asbestos can emitted in the air, and management plans are in the 1980s and 1990s accounted for the be managed safely by preventing damage to established accordingly. Therefore, it is desir- highest percentage, and one of the preschools ceiling textiles and paint on walls and ceil- able for Korea also to establish maintenance where asbestos was detected was a preschool ings, by using wallpapers and gap-filling plans in consideration of the potential for air- located in the Gangnam borough, which is an materials, and by applying stabilizers. borne asbestos, as well as the costs associated economically advantaged area in Seoul. There was also a report in the U.S. that with managing the risk (Yoon, 2009). Korea has prohibited the use of asbestos asbestos concentrations are not high in build- The metropolitan government in Seoul is since 2009, and thus new buildings are made ings on a daily basis, and thus it is appropriate continuing to remove asbestos in multiuse

July/August 2017 • Journal of Environmental Health • Volume 80, Number 1 E4 E-JOURNAL BONUS ARTICLE

FIGURE 4 TABLE 3 Transmission Electron Distribution of Airborne Asbestos in Preschools by Construction Year Microscopy Image of Detected With Transmission Electron Microscopy Chrysotile in a Preschool Construction Year Preschool Airborne Asbestos Transmission Electron Detected at Preschool Microscopy ≤1980 2 0 ND 1981–1990 13 1 0.0072 s/cc (Guro borough) 1991–2000 26 1 0.0036 s/cc (Gangnam borough) ≥2000 5 0 ND Total 46 2 –

ND = not detected. Note. Asbestos was detected by applying the Asbestos Hazard Emergency Response Act method (length ≥ 0.5 μm, width > 0.25 μm, and a length-to-width ratio ≥ 5:1).

Conclusion ered with wallpapers and paints. Therefore, Asbestos of matrix type: 5.4 μm x 0.7 μm (length x width). Young children in the process of physical devel- the most appropriate method is to regularly opment have weaker immune systems and are monitor asbestos, develop and apply effective more sensitive to pollutants than adults— measures and technology to prevent airborne buildings owned by the city year by year. This thus it is important to establish measures to asbestos, and minimize exposure to asbestos action is taken out of consideration for the prevent airborne asbestos in preschools that until it is removed. health of citizens, as many citizens use such were built with materials containing asbes- buildings. Considering the fact that most tos. In particular, even though small-scale Acknowledgement: The authors would like to small-scale preschools are private properties preschools smaller than 430 m2 account for thank director Seokju Cho; Miok Song, PhD; where asbestos is rarely detected, it is desir- 90.4% of preschools in Korea, there are no and Jinhyo Lee, PhD, from the Seoul Insti- able to implement strict preventive measures legal standards for the detection, control, and tute of Health and Environment for providing and perform regular monitoring. We believe management of asbestos in such places. This invaluable advice and input. that it is possible to be safe from asbestos as study examined airborne asbestos concentra- long as we properly maintain and manage the tions in small-scale preschools and discovered Corresponding Author: Changkyu Kim, Par- buildings containing asbestos, like the small- that the asbestos levels met national stan- ticle Research Team, Institute of Public Health scale preschools in this study. In other words, dards, even though a small amount of chryso- and Environment, Seoul Metropolitan Gov- despite the harmfulness of asbestos, the risks tile was detected in a few of the preschools. ernment Research, 202-3, Yangjae-dong, Seo- can be reduced by effective maintenance to Most preschools were preventing exposure to cho-gu, Seoul, Korea, 137-130. prevent airborne emission. asbestos because walls and ceilings were cov- E-mail: [email protected].

References Agency for Toxic Substances and Disease Registry. (2001). Toxic sub- International Agency for Research on Cancer Working Group on stances portal—Asbestos. Retrieved from https://www.atsdr.cdc. the Evaluation of Carcinogenic Risk to Humans. (2012). Asbes- gov/substances/toxsubstance.asp?toxid=4 tos (chrysotile, amosite, crocidolite, tremolite, actinolite and Bernstein, D., Dunnigan, J., Hesterberg, T., Brown, R., Velasco, J.A., anthophyllite). In Arsenic, metals, fibres and dusts. Lyon, France: Barrera, R., . . . Gibbs, A. (2013). Health risk of chrysotile revis- International Agency for Research on Cancer (IARC Monographs ited. Critical Reviews in Toxicology, 43(2), 154–183. on the Evaluation of Carcinogenic Risks to Humans, No. 100C). Comprehensive Information Network for Asbestos Management. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK304374 (2014). The number of preschools in Korea. The Ministry of Envi- International Organization for Standardization. (1995). Ambi- ronment [Website in Korean]. Retrieved from http://asbestos. ent air—Determination of asbestos fibres—Direct transfer me.go.kr/user/gc/asbStaStrPstCdt_new.do transmission electron microscopy method (ISO 10312:1995).

July/August 2017 • Journal of Environmental Health • Volume 80, Number 1 E5 E-JOURNAL BONUS ARTICLE

References Retrieved from http://www.iso.org/iso/catalogue_detail.htm?csnum Ministry of Health and Welfare (Korea). (2012). Asbestos survey on ber=18358 child care center and development of asbestos management stan- Jeong, J.-W., Cho, S., Park, G.-T., & Lee, S.-J. (2013). Health risk dard model (page 1). assessment and evaluation of asbestos release from asbestos- Mirabelli, D., Calisti, R., Barone-Adesi, F., Fornero, E., Merletti, F., cement slate roofing buildings in Busan.Journal of Environmental & Magnani, C. (2008). Excess of mesotheliomas after exposure Science International, 22(12), 1579–1587. to chrysotile in Balangero, Italy. Occupational and Environmental Kang, S.-K., & Kim, E.A. (2010). Occupational diseases in Korea. Medicine, 65(12), 815–819. Journal of Korean Medical Science, 25(Suppl), S4–S12. Paik, N.W., & Lee, Y.H. (1991). Characterization of worker expo- Kim, H.R. (2009). Overview of asbestos issues in Korea. Journal of sure to airborne asbestos in asbestos industry. Journal of Korean Korean Medical Science, 24(3), 363–367. Society of Occupational and Environmental Hygiene, 1(2), 144–153. Lange, J.H. (2001). Airborne asbestos concentrations during abate- Park, D., Choi, S., Ryu, K., Park, J., & Paik, N. (2008). Trends in ment of floor tile and mastic: Evaluation of two different contain- occupational asbestos exposure and asbestos consumption over ment systems and discussion of regulatory issues. Indoor and Built recent decades in Korea. International Journal of Occupational and Environment, 10(3–4), 193–199. Environmental Health, 14(1), 18–24. Lee, R.J., & Van Orden, D.R. (2008). Airborne asbestos in buildings. U.S. Environmental Protection Agency. (1987). Asbestos Hazard Regulatory Toxicology and Pharmacology, 50(2), 218–225. Emergency Response Act, 40 CFR Part 763, Appendix A to Sub- Ministry of Environment of Korea. (2010). Indoor air quality pro- part E. Retrieved from http://www.epadatadump.com/pdf-files- cess test standard (Ministry of Environment Notice No. 2010-24) 2013/2003pt763_0.pdf [Notice in Korean]. Retrieved from http:/me.go.kr/home/web/ Yoon, C.-S. (2009). Critical issues on health risk of asbestos. Korean policy_data/read.do?menuId=10276&seq=6559 Journal of Environmental Health Sciences, 35(5), 426–432. Retrieved Ministry of Environment of Korea. (2017). Indoor air quality con- from http://www.koreascience.or.kr/journal/JournalIssueList.jsp? trol act, article 4 (Ministry of Environment Enforcement Rule No. kojic=HROSBE&volno=35&issno=5&cnov_no=&year_GB=2009 681) [Rule in Korean]. Retrieved from http://www.korealaw.go.kr/ lsInfoP.do?lsiSeq=126651#0000

July/August 2017 • Journal of Environmental Health • Volume 80, Number 1 E6