1. Division of Health Education and Promotion and Agency for Toxic Substances and Disease Registry (ATSDR) Dean S. Seneca, MPH, MCURP, Health Scientist Policy, Tribal Portfolio, Portfolio Management Program, Office of the Chief of Public Health Practice, Centers for Disease Control and Prevention Tribal Environmental Health Education Program

2. ATSDR’s Mission “To serve the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and disease related to toxic substances.”

3. ATSDR Regional Offices

4. Mandated Functions ATSDR is directed by congressional mandate to perform specific functions about the public health effects of hazardous substances in the environment. These functions include: ATSDR is directed by congressional mandate to perform specific functions about the public health effects of hazardous substances in the environment. These functions include:  public health assessments and consultations  health surveillance and registries  response to emergency releases  applied research  education and training

5. What Does ATSDR Do? Determines the extent of danger to public health from hazardous substances Determines the extent of danger to public health from hazardous substances Provides and explains results of evaluations, medical consultations, and investigations to communities and tribes Provides and explains results of evaluations, medical consultations, and investigations to communities and tribes Provides environmental health education to health care providers, communities, and tribes Provides environmental health education to health care providers, communities, and tribes Conducts periodic surveys and screening Conducts periodic surveys and screening

6. ATSDR Does Not Conduct large-scale site-related environmental sampling Conduct large-scale site-related environmental sampling Enforce regulations Enforce regulations Provide medical treatment and health care services Provide medical treatment and health care services

7. Office of Tribal Affairs (OTA) Provides a point of contact for tribes to access ATSDR and its environmental public health programs Provides a point of contact for tribes to access ATSDR and its environmental public health programs Ensures availability of staff to help others within the agency coordinate effectively with tribes Ensures availability of staff to help others within the agency coordinate effectively with tribes

8. Office of Tribal Affairs (OTA) Four Key Services: 1. Serves as a central conduit for tribes to access agency programs and services 2.Assists ATSDR in responding to presidential executive orders and federal mandates concerning tribes

9. Office of Tribal Affairs (OTA) Four Key Services (continued) : 3.Develops, in collaboration with tribes, ATSDR American Indian/Alaska Native policies 4.Coordinates programs and projects to support tribal-specific public health needs

10. ATSDR Tribal Consultation Policy Respects and honors the sovereignty of tribes, the responsibilities and rights to self- governance, and the differences between tribal nations and individuals Respects and honors the sovereignty of tribes, the responsibilities and rights to self- governance, and the differences between tribal nations and individuals Consults with tribal governments to ensure community concerns and impacts are carefully considered before the agency takes action or makes decisions affecting tribal communities Consults with tribal governments to ensure community concerns and impacts are carefully considered before the agency takes action or makes decisions affecting tribal communities

11. ATSDR Tribal Consultation Policy Maintains government-to-government relationships with tribes Maintains government-to-government relationships with tribes Ensures ongoing communication with tribal governments, communities, and individual tribal members to define concerns about possible adverse health impacts from exposures to hazardous substances Ensures ongoing communication with tribal governments, communities, and individual tribal members to define concerns about possible adverse health impacts from exposures to hazardous substances

12. Environmental Issues: “Land Is Life” Threat to subsistence lifestyles: fish consumption, plants (medical purposes), and animals Threat to subsistence lifestyles: fish consumption, plants (medical purposes), and animals Threat to cultural practices: sweat lodges, basket weaving, and pottery making Threat to cultural practices: sweat lodges, basket weaving, and pottery making Polluted land and waterways: environmental compensation Polluted land and waterways: environmental compensation

13. Environmental Issues Emotional trauma Emotional trauma Physiologic trauma Physiologic trauma Physical trauma Physical trauma Spiritual trauma Spiritual trauma

14. Exposure Pathways

15. Exposure Pathways: Definition An exposure pathway describes how people come into contact with a chemical An exposure pathway describes how people come into contact with a chemical

16. Exposure Pathways: Elements An exposure pathway is made up of five elements: 1.Source of contamination (e.g., landfill) 2.Environmental medium through which contaminants travel (e.g., water) 3.Point of exposure (e.g., water tap) 4.Route of exposure (keep in mind cultural practices that might result in exposure) 5.Exposed population

17. Environmental Medium Water Water Air Air Soil Soil Sediment Sediment Animals Animals Livestock, fish, birds Livestock, fish, birds Plants (medicinal and agricultural) Plants (medicinal and agricultural)

18. Routes of Exposure Ingestion (eating and drinking) Ingestion (eating and drinking) Inhalation (breathing) Inhalation (breathing) Dermal (skin contact) Dermal (skin contact) Injection (medicinal or accidental) Injection (medicinal or accidental) Human (placenta, breast milk) Human (placenta, breast milk)

19. Groundwater release Air release Source Little environmental contact. Few exposure pathways. © Harris and Harper (1997) Typical Exposure Assessment Model, Suburban Lifestyle

20. Decomposition and release of long-lived contaminants Uptake from water and sediment Human food, other uses Habitat, feed Caveat: dietary surveys cannot identify all of the links and pathways for even a single species (cattail) Reeds: food storage baskets Pollen: cakes Roots: baked Soil contact while collecting and preparing © Harris and Harper (2000)

21. Traditional Practices Food People are inextricably intertwined with the environment through unique and multiple uses of resources for food, cultural, ceremonial, and religious practices. Contamination Reeds Cooking Pot Water © Harris and Harper (1997) Sleeping mats, Basket Clothing, Shelter

22. Tribal Repatriation of Sacred Objects: Public Health Issues

23. Contaminated Collections: Preservation, Access, and Use Preservation of Native American and Historical Natural History Collections Contaminated with Pesticide Residues Preservation of Native American and Historical Natural History Collections Contaminated with Pesticide Residues  Shepherdstown, WV  April 6-9, 2001

24. Native American Graves Protection and Repatriation Act (NAGPRA) Passed in 1990 Passed in 1990 In the year prior, 1989, National Museum of the American Indian Act passed, facilitating repatriation of objects held within the collection of the Smithsonian Museum In the year prior, 1989, National Museum of the American Indian Act passed, facilitating repatriation of objects held within the collection of the Smithsonian Museum

25. NAGPRA …conduct an inventory and return any human remains, funerary objects, sacred objects and objects of cultural patrimony belonging to Native Americans …conduct an inventory and return any human remains, funerary objects, sacred objects and objects of cultural patrimony belonging to Native Americans In 1996, added requirement for notification of known pesticide or other chemical contamination associated with the objects In 1996, added requirement for notification of known pesticide or other chemical contamination associated with the objects

26. As, Hg, pesticides, DDT, Naphthalene, dichlorvos, dichlorobenzene, strychnine, sulfur, camphor, tobacco, ethylene dibromide, and other chemicals were used to prevent damage from insects and rodents As, Hg, pesticides, DDT, Naphthalene, dichlorvos, dichlorobenzene, strychnine, sulfur, camphor, tobacco, ethylene dibromide, and other chemicals were used to prevent damage from insects and rodents

27. Smithsonian Museum of Natural History Collection: Treatments Used to Prevent Damage from Insects and Rodents Early 1800’s Early 1800’s  As, Hg Mid-1800’s Mid-1800’s  As, Hg, tobacco, sulfur, camphor, heat Late 1800’s/Early 1900’s Late 1800’s/Early 1900’s  As, Hg, strychnine, carbolic acid, naphthalene, wax/solvents, carbon disulfide Mid 1900’s Mid 1900’s  Dichlorobenzene, hydrocyanide gas, aluminum silicate, DDT, ethylene dichloride, carbon tetrachloride, ethylene dibromide, dichlorvos, sulfuryl fluoride, freezer

28. Evaluation of Carcinogenicity to Humans (IARC) CategoryAgent 1-human carcinogenArsenic, Silica 2A-probable human Ethylene dibromide carcinogen 2B-possible humanCarbon Tetrachloride, carcinogenDDT, Dichlorobenzene, Dichlorvos, Hg

29. Potential for Exposure to Chemical Preservatives Dermal exposure Dermal exposure  masks may be worn for ceremony Inhalation Inhalation  off-gassing may occur from preserved artifact and in enclosed spaces may be a source of exposure Ingestion Ingestion  hand to mouth activity from small children

30. Characterize Risk to the Affected People and their Eco-cultural Systems Ecological Exposure Cultural Exposure Ecological Toxicity and Sensitivity Cultural Toxicity and Sensitivity Identify What Is “At Risk” - Resources at Risk - Human Systems and Uses at Risk - Existing Stressors New first step in CERCLA risk assessments Risk = exposure x sensitivity There is such as thing as Cultural Exposure and Toxicity. Characterization of Cumulative Risks requires that all risks and impacts be included within the risk assessment framework. Characterize Ecological Risk Hazard Identification - Probability - Severity Fate and Transport - Contamination of Media, - Contamination of Resources - Point and Aerial Extent Over Time Human Exposure Human Toxicity and Sensitivity Characterize Human Health Risk Characterize Cultural Risk Also known as Quality of Life Expanded Risk Framework © Harris & Harper, 1999

31. General Health Effects of Agents Found on Museum Artifacts Arsenic Arsenic  GI disturbances, skin lesions, peripheral neuropathy, anemia, cardiovascular effects, skin and lung cancer  Lab –Urine levels for recent exposure (r/o dietary sources) Mercury Mercury  Gingivitis, tremor, renal damage, neuropsychiatric manifestations  Lab –Urine levels of low-molecular weight proteins. Urine and blood mercury levels (r/o dietary sources)

32. General Health Effects of Agents Found on Museum Artifacts (cont.) Naphthalene Naphthalene  Dermatitis  Lab–Urine biomarker and blood hydrocarbon DNA-adduct (r/o dietary and tobacco smoking sources) DDT DDT  Irritant, GI disturbances, central nervous system effects, suspect fetotoxicity, possible liver/kidney damage, suspect carcinogen  Lab–Serum DDT levels and urine metabolite

34. Repatriation Issues Should each object be tested prior to return to Tribes? Should each object be tested prior to return to Tribes? Are there safe decontamination procedures? Are there safe decontamination procedures? Tribal recipient health risks? Tribal recipient health risks? Museum worker health risks? Museum worker health risks? Handling protocols? Handling protocols? Research on extent of health effects among exposed groups? Research on extent of health effects among exposed groups?

36. Contaminants of Concern

37. Effects of Exposure Health effects of exposure to any hazardous substance depend on the: Health effects of exposure to any hazardous substance depend on the:  Dose (how much)  Duration (how long)  Event (how the exposure happens)  Health, traits, and habits of the person exposed  Presence of other chemicals

38. Lead What: A bluish-gray metal with many uses What: A bluish-gray metal with many uses How: Exposure is usually by ingestion or inhalation How: Exposure is usually by ingestion or inhalation Where: Exposure can occur from Where: Exposure can occur from  Old houses with lead paint  Working in a job where lead is used  Hobbies  Folk remedies

39. Lead: Health Effects Lead affects almost every organ and system of the body Lead affects almost every organ and system of the body The central nervous system is the most sensitive, especially in young children The central nervous system is the most sensitive, especially in young children In children, lead can cause developmental delays, anemia, severe stomachache, and muscle weakness In children, lead can cause developmental delays, anemia, severe stomachache, and muscle weakness Lead can also damage the kidneys and reproductive system Lead can also damage the kidneys and reproductive system

40. Cadmium What: Usually occurs as a mineral combined with other elements What: Usually occurs as a mineral combined with other elements How: Exposure is usually by inhalation or ingestion How: Exposure is usually by inhalation or ingestion Where: Exposure can occur from Where: Exposure can occur from  Eating foods with cadmium (highest in shellfish and liver and kidney meats)  Smoking cigarettes  Working in a job where cadmium is used (battery manufacturing, welding)

41. Cadmium: Health Effects Severely damages lungs Severely damages lungs Causes stomach irritation, vomiting, and diarrhea Causes stomach irritation, vomiting, and diarrhea Causes kidney disease Causes kidney disease Makes bones fragile Makes bones fragile

42. Polychlorinated Biphenyls (PCBs) What: Colorless to light yellow oily liquids or solids. No known natural sources. What: Colorless to light yellow oily liquids or solids. No known natural sources. How: Exposure is usually by skin contact, inhalation or ingestion How: Exposure is usually by skin contact, inhalation or ingestion Where: Exposure can occur from Where: Exposure can occur from  Eating foods with PCBs (mainly fish)  Working in a job involving transformers, fluorescent lights, or other electrical devices  Breathing air near hazardous waste sites

43. PCBs: Health Effects Skin conditions (acne, rashes) Skin conditions (acne, rashes) Liver damage Liver damage May cause cancer May cause cancer

44. Pesticides What: A mixture of many chemicals used to control unwanted insects indoors or outdoors What: A mixture of many chemicals used to control unwanted insects indoors or outdoors How: Exposure is usually by inhalation or ingestion How: Exposure is usually by inhalation or ingestion Where: Exposure can occur from Where: Exposure can occur from  Residues in food  Living or working on or near a farm where pesticides are sprayed on crops  Breathing air near hazardous waste sites

45. Pesticides: Health Effects Acute exposure (high levels, short term) may cause flu-like symptoms Acute exposure (high levels, short term) may cause flu-like symptoms Chronic exposure (longer term) may cause skin damage, cancers, and reproductive problems Chronic exposure (longer term) may cause skin damage, cancers, and reproductive problems

46. Mercury What: Naturally occurring metal; a silver liquid that turns to a gas when heated. Methylmercury is an organic compound. What: Naturally occurring metal; a silver liquid that turns to a gas when heated. Methylmercury is an organic compound. How: Exposure is usually by inhalation, ingestion, or skin contact How: Exposure is usually by inhalation, ingestion, or skin contact Where: Exposure can occur from Where: Exposure can occur from  Eating contaminated fish or shellfish (methylmercury)  Breathing vapors from spills, contaminated air  Religious or ethnic practices (e.g., Hispanic, Haitian)

47. Mercury: Health Effects Harmful to the central nervous system, especially in unborn babies and children Harmful to the central nervous system, especially in unborn babies and children Can damage brain, kidneys, and digestive system Can damage brain, kidneys, and digestive system Acute exposure may cause nausea, vomiting, diarrhea, increased blood pressure or heart rate, and skin rashes Acute exposure may cause nausea, vomiting, diarrhea, increased blood pressure or heart rate, and skin rashes

48. Mold What: Type of fungus that lives on plants, foods, and other organic materials What: Type of fungus that lives on plants, foods, and other organic materials How: Exposure is usually by inhalation How: Exposure is usually by inhalation Where: Exposure can occur from Where: Exposure can occur from  Indoor moisture caused by flooding, leaky roofs or plumbing, and humidifiers  Areas with high levels of humidity

49. Mold: Health Effects A higher risk of health effects may be seen in children, the elderly, and persons with existing respiratory conditions or compromised immune systems A higher risk of health effects may be seen in children, the elderly, and persons with existing respiratory conditions or compromised immune systems Causes respiratory irritation (wheezing, nasal and sinus congestion, cough, and shortness of breath) Causes respiratory irritation (wheezing, nasal and sinus congestion, cough, and shortness of breath)

50. Other Contaminants Silver Silver Uranium Uranium Cyanide Cyanide Benzene Benzene Silica Silica Iodine 131 Iodine 131 Methyl tert-butyl ether (MTBE) Methyl tert-butyl ether (MTBE)

51.  ATSDR uses EPA’s Cancer Slope Factors (CSFs) to calculate risk  Risk = Exposure Dose x CSF  Results in a maximum additional cases of cancer in a population (theoretical risk)  “Health Guideline” for cancer risk is usually 1 in 10,000 or 10 -4  One additional case of cancer in a lifetime of exposure per ten thousand individuals. Calculating Cancer Risk

52. Cancer Risk Concepts Actual Risk of Cancer may be zero 95% Upper Bound Risk of Cancer at Specific Dose by Direct Extrapolation DOSE RESPONSE Actual Data Points

53. Cancer Slope Factor units: (mg/kg/day) -1 - estimated from studies CVs – e.g. CREG (units: mg/kg or mg/L or ug/m3) 2)Convert dose (mg/kg/day) to env. concentrations, using conservative assumptions. 1)Calculate dose at “1 in a million” risk level, where excess Cancer Risk = Dose x Cancer Slope Factor.

54. For cancer evaluation: Select a Contaminant as a “Contaminant of Concern” if: Its concentration exceeds a CV, or Its concentration exceeds a CV, or It was detected and is a carcinogen, or It was detected and is a carcinogen, or Its detection limit exceeds the CV and it may occur at the site (remember non- detect = 0), or Its detection limit exceeds the CV and it may occur at the site (remember non- detect = 0), or There is no CV. There is no CV.

55. Examples of Cancer Clusters Leading to Identification of Human Carcinogens Occupational 1775: Scrotal cancer in chimney sweeps exposed to soot from coal (8) 1929: Osteosarcoma in watch dial painters exposed to radium (9) 1965: Mesothelioma and lung cancer in asbestos workers (10) 1974: Angiosarcoma of liver in chemical workers exposed to vinyl chloride monomer (11) Medical 1971: Vaginal clear cell carcinoma in daughters exposed to in utero diethylstilbesterol (12) Other 1981: Kaposi sarcoma in homosexual men with AIDS exposed to human herpes-virus-8 (13)

56. Want More Information? ATSDR Web Page ATSDR Web Page  http://www.atsdr.cdc.gov ATSDR’s toll-free number ATSDR’s toll-free number  1-888-42-ATSDR (1-888-422-8737) OTA Web Page OTA Web Page  http://www.atsdr.cdc.gov/tribal