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Human Health Risk Assessment in the Coeur d’Alene River Basin

INTRODUCTION

The objective of this chapter is to present an overview of the manner in which a human health risk assessment (HHRA) is conducted and then to describe in stepwise fashion the procedures that the U.S. Environmental Protection Agency (EPA) and its partners followed in conducting the Coeur d’Alene River basin HHRA (TerraGraphics et al. 2001). The Coeur d’Alene River basin HHRA for the area extending from Harrison to Mullan, Idaho, was jointly prepared by the Idaho Department of Health and Welfare (IDHW), the Idaho Department of Environmental Quality, and EPA Region 10. Oversight and guidance were provided by the Governor’s Advisory Council on Human Health Risk Assessment, which included the Lieutenant Governor of Idaho. The five-member EPA Technical Review Workgroup for lead ultimately conducted an independent review of the document. Finally, numerous citizens, tribal representatives and community organizations provided or facilitated reviews and comments of a public draft of the document. Below, we summarize and critique the outcome of that effort. It should be noted that issues that the committee considered as the most important are emphasized in the review. A comprehensive and exhaustive review of all assumptions used in EPA’s assessments and their underlying scientific basis was beyond the scope of what the committee could be expected to accomplish.



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5 Human Health Risk Assessment in the Coeur d’Alene River Basin INTRODUCTION The objective of this chapter is to present an overview of the man- ner in which a human health risk assessment (HHRA) is conducted and then to describe in stepwise fashion the procedures that the U.S. Environ- mental Protection Agency (EPA) and its partners followed in conducting the Coeur d’Alene River basin HHRA (TerraGraphics et al. 2001). The Coeur d’Alene River basin HHRA for the area extending from Harrison to ­ ullan, Idaho, was jointly prepared by the Idaho Department of Health M and Welfare (IDHW), the Idaho Department of Environmental Quality, and EPA Region 10. Oversight and guidance were provided by the Governor’s Advisory Council on Human Health Risk Assessment, which included the Lieutenant Governor of Idaho. The five-member EPA Technical Review Workgroup for lead ultimately conducted an independent review of the document. Finally, numerous citizens, tribal representatives and community organizations provided or facilitated reviews and comments of a public draft of the document. Below, we summarize and critique the outcome of that effort. It should be noted that issues that the committee considered as the most important are emphasized in the review. A comprehensive and exhaus- tive review of all assumptions used in EPA’s assessments and their underly- ing scientific basis was beyond the scope of what the committee could be expected to accomplish. 161

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162 superfund and mining megasites General Objectives of an HHRA The objectives of an HHRA are two-fold: first, to estimate the level of risk to human health associated with concentrations of environmental con- taminants; and second, if that risk is found to be unacceptable, to calculate media-specific cleanup levels that will protect human health. Risks are estimated for current uses of a site as well as foreseeable future ­ uses. All contaminated media are considered (for example, soil, water) if individuals are likely to be exposed to the media. All relevant routes of exposure are also considered, including direct contact, such as inhalation, ingestion, and dermal exposure, and indirect contact, such as exposure to vegetables that have taken up contaminants through the soil or water. Cleanup levels are calculated based on the relationship between con- taminants and risk as defined in the risk assessment and a policy decision (risk management) about the level of risk that is considered acceptable. As a result, cleanup levels for a single contaminant can vary from one site to another either because the relationship between environmental levels and risk differs or because different policy decisions have been made concerning the level of acceptable risk. Overview of the Superfund HHRA Process HHRA typically is described as including four steps: hazard identifica- tion, exposure assessment, toxicity assessment, and risk characterization. Early in the development of the field of risk assessment, hazard identification referred to determining which chemicals or compounds at a site could lead to risk. Today, the list of chemicals and compounds with associated human health risks are well known, and the first step has changed to data collection and analysis, including collecting data on the characteristics of the site and the chemicals or compounds of concern. The second step in HHRA involves exposure assessment, including iden- tifying the populations of individuals exposed to hazards at the specific site and how those exposures may occur. For example, the Coeur d’Alene River basin HHRA identifies children as the primary population of concern for lead exposure and identifies the presence of local American Indian popula- tions. Potential pathways of exposure are defined, such as children ingesting soil and house dust contaminated with lead, and American Indian ingestion of locally grown foods contaminated with lead. At other sites, exposures could include scenarios such as inhalation and dermal exposure to vola- tile chemicals in groundwater while showering. In addition to identifying the potential pathways of exposure, this step may involve defining several p ­ arameters (for which there are insufficient measured data) that will govern the estimated risk from each exposure pathway. These are often referred to

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HUMAN HEALTH RISK ASSESSMENT 163 as assumptions, or default values, and they are assumed to be representative of a population, although they often include a conservative safety factor. These parameters include things such as time spent indoors and outdoors, which can differ as a function of climate. The third step is toxicity assessment, or identifying and quantifying a chemical’s or compound’s intrinsic toxic properties. Again, at this point in the development of risk assessment, based on numerous controlled ani- mal and/or human experiments and on epidemiological studies, toxicity ­ arameters have been established by EPA and other agencies for many of the p major chemicals and compounds. At times, when a great deal of information is known about a compound’s toxicity, this step involves examining an EPA database for the chemical-specific cancer slope factor (SF) or reference dose. But for many compounds found at Superfund sites, much less is known, and there are myriad assumptions made that often prove very controversial. The fourth step, risk characterization, combines the results of the first three steps into an estimate of risk. The estimated risk is then compared with a level of risk deemed “acceptable” according to risk management decisions (see below), and the site is thereby identified as either having acceptable risk levels or in need of remedial measures. All the risk assessment steps described above inherently incorporate uncertainty. Each of the steps generally involves extrapolation from obser- vations in one set of circumstances (for example, the effect of known, high doses of a chemical given to laboratory animals over a short period) to the circumstances of interest (for example, the potential effects of unknown, small doses of a mixture including the tested chemical on humans over a lifetime). Each such extrapolation introduces qualitative and quantitative uncertainties; and an adequate hhra should describe qualitatively—and, if possible, quantitatively the sizes and types of such uncertainties. One additional tenet of the Superfund HHRA process bears discussion, and that is EPA’s preferred focus on the individual with reasonable maximum exposure (RME). A risk assessment generally includes a calculated estimate of the likely risks for an average individual—the central tendency (CT)—and for an individual experiencing RME conditions. EPA defines RME as the highest exposure that is reasonably expected to occur at a site. Generally, the RME risk is compared with the acceptable level of risk when determining whether remedial measures are needed. If risks are found to be unacceptable, thus requiring remediation, then the models used in the risk assessment can also be used to determine acceptable concentrations of contaminants, equated to “cleanup levels.” It is important to note that a cleanup level calculated in this way is applicable over the same geographic area that was assessed in the risk calculation and represents the same mathematical formulation used for the concentra- tion term in the risk assessment. For example, if the chronic risk to a child

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164 superfund and mining megasites exposed over several years to the average contaminant concentration in his/ her yard is found to be unacceptable, then a cleanup level derived from the corresponding risk equation will represent the acceptable average concentra- tion for soil in the yard. As a further example, if a risk calculation focused solely on a heavily used play area finds unacceptable risk, then the cleanup level calculated from that risk equation will represent the acceptable average concentration for the play area. However, the derivation of an actual cleanup level is typically controversial, partly due to the uncertainties associated with each piece of information that go into the mathematical derivation of the cleanup number. Finally, a distinction needs to be drawn between risk assessment and risk management. Simply put, risk assessment is scientific and involves identify- ing pathways of exposure and some mathematical calculations; risk man- agement involves policy and societal values. Cleanup levels are calculated on the basis of a policy decision about the level of acceptable risk as well as on the basis of the mathematical risk assessment. Further, the assessment of uncertainty in a risk assessment may lead to the development of more than one possible cleanup level or a range of cleanup levels. A risk manager will choose a cleanup level from the range after considering other site character- istics such as technical feasibility of the remediation, public desires, and so forth. As a result, a cleanup level may not be directly linked to an actual risk calculation, but it is generally expected that the cleanup level chosen during the risk management process will fall within a range developed in the course of the risk assessment. Geographic Area Considered in the Coeur d’Alene River Basin HHRA The Coeur d’Alene River basin HHRA considered an area that included the South Fork of the Coeur d’Alene River, its tributaries, and the main stem of the river west of its confluence with the North Fork. The region of inter- est spans roughly 53 miles from the Idaho-Montana border to Lake Coeur d’Alene and excluded the 21-square-mile Bunker Hill Super­und site. The f towns of Mullan, Osburn, Wallace, and parts of Pinehurst, Idaho, are all included and all lie within Shoshone County. Demographics of the Population The demographic characteristics of the Coeur d’Alene River basin are primarily a function of its mining past and were strongly affected by the closure of the Bunker Hill smelter in 1981. Since the smelter ceased opera- tions, the region has suffered chronically high unemployment, averaging 12.3% in the 1990s, about twice the state average. In 2001, the per capita income was just over $19,000, or 78% of the state value (Idaho Department

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HUMAN HEALTH RISK ASSESSMENT 165 of Commerce 2004). The lower wage base is accompanied by an increase in poverty; according to the 2000 U.S. census, 12.4% of the families and 16.4% of the individuals in rural Shoshone County lived below the poverty level during 1999. These values were higher than the statewide values of 8.3% and 11.8%, respectively. With the lack of a viable economic base, there has been a gradual out-migration of people from Shoshone County; due to limited turnover of the population, the county’s age and racial pro- files do not generally reflect those of the state as a whole. For example, the median age for Idaho was 33 years in 2000, but in the mining communities of the river basin, it was over 40 years. Racially, the county’s population of 13,771 was predominantly white (96% white versus 93% for Idaho), with small American Indian (1.5%) and Hispanic populations (1.9%) versus 2.1% and 7.9%, respectively, statewide. The total population of the river basin areas addressed in the HHRA was 10,496 based on 1990 census data (­ erraGraphics et al. 2001, Table 3-4). Children aged 0 to 4 years—a popula- T tion cohort that is particularly susceptible to lead toxicity—made up 5.6% of the population (587 children).1 CHEMICALS OF CONCERN IN THE COEUR D’ALENE RIVER B ­ ASIN: HAZARD IDENTIFICATION The database of environmental chemical analyses available for the HHRA process was extensive and included thousands of analyses of metals in soil, house dust, groundwater, homegrown vegetables, sediment, surface water, fish, and edible wild plants (water potatoes) in the river basin. Typically, for each sample, the precise geographic location and concentrations of up to 23 metals and other inorganic materials were ascertained. For example, 4,000 soil and sediment samples were collected within the study area and analyzed for 23 inorganic compounds. Yard soils from 1,020 homes throughout the river basin were analyzed for lead, corresponding to roughly one-quarter of the yards present in the river basin in the 1990 census. Soils from 191 residential yards were analyzed for 23 inorganic compounds. Before chemical analysis, all soil samples were sieved to obtain soil particles less than 175 micrometer (µm) in diameter. Pre-sieving is justified by the observation that fine particles preferentially adhere to hands (Duggan et al. 1985; Duggan and Inskip 1985; Sheppard and Evenden 1994; Kissel et al. 1996) and the assumption that they are therefore more likely to be ingested. Dust mats were placed and collected from 500 river basin homes, and vacuum cleaner bags were collected from 320 of those homes. Measurements of these samples allowed for estimates of both lead concentration and dust loading rates. Tap water from 100 homes 1The HHRA compiled population estimates from 1990 census tracts that were within or partially within the HHRA study area.

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166 superfund and mining megasites was analyzed for 23 inorganic compounds, and 425 homes had water lead analyzed. Eighty samples of water from 27 monitoring wells near Ninemile and Canyon Creeks were analyzed for 23 inorganic compounds. X-ray fluo- rescence measurements of lead concentrations on interior and exterior surfaces were performed in 415 homes. While this tabulation could go on, the point is that a substantial environmental database was available to the risk assessors as they sought to quantify chemicals of concern from a variety of media in the Coeur d’Alene River basin environment that might pose a risk to human health. Because of the large geographic area of the river basin, additional stud- ies of specific areas will be required as reme­ iation proceeds. d Not all substances present at various test sites pose a human health risk. For example, some of the numerous metals present in environmental samples from the river basin are essential nutrients, including zinc, calcium, iron, magnesium, potassium, and sodium. Yet even these, in excess, can pose health risks. Thus, EPA has developed guidelines for selecting a group of chemicals of potential concern (COPCs) based on their toxicity, con- centration, and other factors (EPA 1989). Typically, applicable or relevant and appropriate requirements (ARARs) are used to compare the observed concentration of a substance in an environmental sample with some screen- ing value, threshold, or legally defined concentration in that environmental medium. For example, the ARARs for drinking water at this site are actu- ally the EPA maximum contaminant levels (MCLs)—concentrations of substances in drinking water above which unacceptable health risks to the public may occur. The ARARs for surface water are the MCLs as well as the ambient water-quality criteria (AWQC). The latter, used for controlling releases or discharges of pollutants, are protective of those who drink surface water, those who eat fish caught in surface water, and aquatic organisms. The only ARAR for substances in air that is relevant at this site is that for lead—the National Ambient Air Quality Criterion for lead. There are no ARARs at this site for substances in soil or sediments. The river basin HHRA considered which COPCs might pose a human health risk for each medium of possible exposure: soil/sediment, tap water, surface water, groundwater, house dust, air, fish consumption, and home- grown vegetables. The process used was very typical of any HHRA at sites where chemical exposures might occur. In addition, it considered possible risks due to the ingestion of water potatoes, a culturally important food source for the Coeur d’Alene tribe. Because a “screening value” for sub- stances in water potatoes is not known, cadmium and lead were evaluated as substances with possible risk, a decision consistent with the evaluation of other food substances. As a result of these hazard-identification activities, selected metals were chosen for further evaluation of human exposure, and a list of possible

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HUMAN HEALTH RISK ASSESSMENT 167 sources of exposure was created for each (Table 5-1). The metals were anti- mony, arsenic, cadmium, iron, lead, manganese, mercury, and zinc. In summary, the HHRA appropriately identified COPCs for each pos- sible source of exposure. However, no effort was made to identify the par- ticular chemical species of lead or arsenic (or other metal) in any of these sources. The absence of chemical speciation is less than ideal because the bioavailability and toxicity of particular chemical species of the same metal can vary substantially. APPROACH USED TO ASSESS HUMAN HAZARDS: EXPOSURE ASSESSMENT After identifying which chemicals might pose hazards to human health, the HHRA set out to characterize human exposure. Because the concentra- tions of metals in various media and exposure profiles in the river basin are not uniform, EPA considered it necessary to divide the region of interest into nine distinct geographical areas: lower basin, Kingston, side gulches, Osburn, Silverton, Wallace, Ninemile, Mullan, and Blackwell Island (­ erra­ raphics et T G al. 2001, Fig. 3-1a). For each of these regions, diagrams were created to con- ceptualize possible pathways of exposures to metals that might occur under several scenarios—for example, during residence in the home, neighborhood recreation, public recreation, occupation, and subsistence living. An example of this approach, for Silverton, Idaho, taken directly from the HHRA, is pro- vided as Figure 5-1 (TerraGraphics et al. 2001). This portion of the HHRA was basically a paper exercise, but one that is based on a rather extensive literature that has documented that such pathways of exposure have resulted in significant chemical exposures in other circumstances. Thus, this approach represents an acceptable technique for eventually estimating potential current and future exposures. TABLE 5-1  Possible Exposure Sources of Chemicals of Potential Concern Possible Exposure Source Chemicals of Potential Concern Soil/sediment Antimony, arsenic, cadmium, iron, lead, manganese, and zinc Tap water Arsenic and lead Surface water Arsenic, cadmium, lead, manganese, and mercury Groundwater Antimony, arsenic, cadmium, lead, and zinc House dust Antimony, arsenic, cadmium, iron, lead, manganese, and zinc Fish Cadmium, lead, and mercury Homegrown vegetables Arsenic, cadmium, and lead Source: TerraGraphics et al. 2001, Table 2-12.

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168 Figure 5-1 Example of conceptual site model diagram from HHRA. , Complete pathway; evaluated quantitatively in the HHRA. , Pathhway potentially complete, but of minor concern; not qualified in the HHRA. A blank cell indicates that the pathway is not complete or the receptor type does not exist in the this area. (a) Quantified for arsenic and cadmium only. See text for discussion. (b) This pathway evaluated quantitatively for nonlead COPCs and quantitatively for lead. (c) Both traditional and modern subsistence tribal member exposure scenarios will be evaluated at a later time.

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HUMAN HEALTH RISK ASSESSMENT 169 Ultimately, to estimate possible risks of adverse health outcomes, it is necessary to estimate the metal concentration in each environmental medium to which an individual may be exposed. EPA guidelines (EPA 1991a, 1992a) state that this concentration term (exposure point concentration [EPC]) should represent the average concentration to which one is exposed for the relevant portion of one’s lifetime. Because of the obvious uncertainty in esti- mating the true average concentration from measurements of samples, EPA recommends using the 95% upper confidence limit (UCL95) of the mean as a conservative estimate of the EPC, because this is associated with only a 5% probability of underestimating the true average (EPA 1991a, 1992b, 1993a). In addition to the concentrations in each environmental medium, it is neces- sary to estimate the pathway-specific intakes from that medium to ultimately estimate exposures. In the Coeur d’Alene River basin HHRA, intakes were estimated in two ways, consistent with EPA guidelines for risk characteriza- tion (EPA 1995). A CT exposure estimate is considered to be representative of average human exposures, whereas a higher value, the RME, illustrates a high-exposure scenario that is nevertheless likely to occur. For each of the nine geographic regions, the Coeur d’Alene River basin HHRA used this approach to estimate point concentrations and intakes of surface soil, vacuum bag dust, floor mat dust, tap water, groundwater, sub- surface soil, waste piles, and sediments. A total of 49 data sets were analyzed rather than 72 (nine regions × eight sources) because not every region had potential exposure from each of these sources. In 38 of 49 cases, at least 10 measured values were available to make this estimate, and in many cases, hundreds of measurements were used, thus providing stable estimates of the true average concentration. In the remaining 11 cases, fewer than 10 mea- surements were available; in these cases, the maximum value was used in place of the UCL95. Because the formula used to appropriately calculate UCL95s depends on the distribution of the data, the HHRA first examined the shape of the distributions before carrying out these calculations. Regional estimates of chemical intakes were subsequently made for soil, sediment, drinking water, surface water, homegrown vegetables, and fish. The exposure models utilized were straightforward and took into account a variety of behavioral and physiological factors, including exposure fre- quency and duration, contact rate, EPC, body weight, and averaging time. An example of one of these models, derived from the HHRA, which esti- mated exposure via the consumption of groundwater as a drinking source, is shown below: Chemical intake (mg/kg/day) = Cw × SIFw × CF (1) and

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170 superfund and mining megasites SIFw = IRw × EF × ED/(BW × AT), (2) where Cw = chemical concentration in groundwater/tap water (µg/L); SIFw = summary intake factor for ingestion of tap water (L/kg/day); IRw = ingestion rate for tap water (L/day); EF = exposure frequency (days/year); ED = exposure duration (years); CF = conversion factor (mg/µg); BW = body weight (kg); and AT = averaging time (days). The intake parameters used to solve such equations (in this case, IRw, EF, ED, BW, and AT) for children and adults were obtained from previ- ous EPA guidance for such calculations (EPA 1989, 1991a, 1993a). In the example presented, the intake parameters are known with a relatively high degree of certainty (for example, ingestion rate for tap water). In other equations, such as those related to exposure from homegrown vegetables or dermal exposure to surface water, intake parameters are less certain (for example, vegetable ingestion rates, and gastrointestinal and dermal absorp- tion factors) but represent conservative estimates of the weight of current scientific evidence. HUMAN HEALTH: TOXICITY ASSESSMENT After identifying the chemical hazards and estimating the human expo- sures to each, the next step in an HHRA involves evaluating the scientific evidence from animal and human epidemiologic studies that have examined dose-response relationships for cancer and noncancer health outcomes. The fundamental tenet of toxicology is that the dose determines the effect. For Carcinogens (Arsenic) For cancer outcomes, the dose-response information is condensed into an SF, in units of (mg/kg-day)–1, which expresses excess cancer risk as a function of (lifetime average) daily dose. EPA maintains an online database, the Integrated Risk Information System (IRIS) (EPA 2004a), which contains SFs that are based on the current weight of toxicologic evidence. Of the metals identified as potential hazards in the river basin, only arsenic was evaluated for carcinogenic risk.2,3 Arsenic’s SF—unchanged since the early 1990s—is based largely on data from international epidemiologic studies that have been reviewed in previous National Research Council (NRC)

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HUMAN HEALTH RISK ASSESSMENT 171 reports (NRC 1999, 2001). Several U.S.-based studies have failed to find an association between arsenic in drinking water and cancer risk in non- smokers (Bates et al. 1995; Lewis et al. 1999; Karagas et al. 2001; Steinmaus et al. 2003), possibly suggesting that the SF may overstate the risks at low doses. In this regard, however, a recent study of arsenic and bladder cancer in New Hampshire that examined individual arsenic exposures using toenail arsenic as a biomarker of exposure found that low-level arsenic exposure was associated with a doubling of the risk for bladder cancer (Karagas et al. 2004). At the present time, a great deal of research concerning arsenic and cancer is ongoing, much of it supported by the Superfund Basic Research Program, and it seems possible that the SF may need to be reex­­ ined in the am­ future as a result of past and ongoing work. For Noncarcinogens Other Than Lead For noncancer outcomes, a chronic reference dose (RfD) is derived from the no-observed-adverse-effect level (NOAEL) or lowest-observed-adverse- effect level (LOAEL) in animals or humans.4 RfDs are derived by dividing the NOAEL or LOAEL by an uncertainty factor that represents a combina- tion of various sources of uncertainty associated with the database for that particular chemical. Once again, EPA’s IRIS database served as a source of RfDs for the chemicals of concern in the basin, except for lead (discussed below) and iron, for which there is no IRIS RfD and for which other sources of toxicity data were used. Note that arsenic also has non­ ancer effects and c its own IRIS RfD. 2EPA’s HHRA for lead did not include cancer as a possible health outcome. In a recent report from the National Toxicology Program (NTP), lead and lead compounds were listed as “reason- ably anticipated to be human carcinogens” (NTP 2005). The committee did not further consider the potential carcinogenicity of lead in its review of EPA’s HHRA. 3EPA’s HHRA for cadmium did not include cancer as a possible health outcome. The Ninth Report on Carcinogens (NTP 2000) listed cadmium and cadmium compounds as known human carcinogens. The HHRA, released in June 2001, states that arsenic was the only estab- lished human carcinogen and that there are no cancer SFs to conduct a quantitative evaluation of cancer risk for other metals. EPA’s IRIS database does not provide a quantitative estimate of carcinogenic risk from oral exposure for cadmium and states, “There are no positive studies of orally ingested cadmium suitable for quantitation” (EPA 2004a). Further, the committee noted ATSDR’s Environmental Health Assessment in the Coeur d’Alene River basin (ATSDR 2000), which reported urine cadmium analyses for 752 Coeur d’Alene River basin residents and that stated, “In contrast to the results for lead, no link between soil or dust exposures and elevated urine cadmium was found in the study population. Rather, elevated cadmium in this population appears to be related to smoking behaviors.” 4More recently, a benchmark dose (BMD) for an appropriate end point may also be used as the starting point, rather than LOAELs or NOAELs.

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212 superfund and mining megasites with mining wastes is a significant source of increased BLLs, although lead paint is also a significant source for children likely to be exposed to that source. Conclusion 4 There are logical reasons to believe that yard remediations decrease exposure to lead, but the scientific evidence supporting substantial beneficial effects is currently weak. Similarly, there is suggestive evidence of efficacy within the Bunker Hill box and river basin. Thus, the strategy for yard reme- diation is supportable. However, the long-term effectiveness of this remedy in the Coeur d’Alene River basin is questionable because of the possibility, even likelihood, of recontamination. Recommendation Long-term support of institutional controls programs should be pro- vided to avoid undue human health risks from recontamination. Moreover, an evaluation of the efficacy of yard remediation should be supported by ongoing environmental and blood lead monitoring efforts. Conclusion 5 Universal blood lead screening of children aged 1-4 years is indicated for this community given the prevalence of high levels of environmental lead. The current practice of annual fixed-site screening is suboptimal and produces results with too much potential for selection bias to evaluate public health intervention strategies used in the basin. Shifting the design from a fixed site to a more widespread screening program utilizing the local health care community likely would increase participation. This type of screening program would provide a participant population that is less likely to be biased. Such a practice could be timed to coincide with other medically indicated health care screening tests con- ducted by primary care physicians. For example, screening for iron deficiency a ­ nemia commonly is conducted for children 1-5 years of age by performing a complete blood count. Blood lead screening could be timed to coincide with this blood draw, thereby minimizing inconvenience to the family and child. Linking the screening program to pediatric well-child visits likely will increase participation, provide built-in follow up for children with elevated BLLs, and be more convenient for families. These health surveillance activi- ties could be conducted or sponsored by local, state, or federal (for example, ATSDR) entities.

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HUMAN HEALTH RISK ASSESSMENT 213 Recommendation The committee recommends that annual blood lead screening of all chil- dren aged 1-4 years living in the basin be initiated in conjunction with local health care providers. Results should be used to evaluate the efficacy of the environmental interventions. Conclusion 6 American Indians who practice traditional lifestyles likely would have higher risks than other residents of the Coeur d’Alene River basin. The con- tamination itself likely interferes with the ability of tribal members to live subsistence lifestyles. The committee agrees with relevant statements in the HHRA—for example, that “it is clear that a subsistence-based lifestyle requires environ- mental lead levels orders of magnitude lower than those measured through- out the floodplain of the Coeur d’Alene River,” and the conclusion that “Estimated lead intake rates for these scenarios are too high to predict BLLs with confidence. Predictions for BLLs associated with subsistence activi- ties . . . would significantly exceed all health criteria for children or adults.” Conclusion 7 There is strong scientific evidence that living in or near a Superfund site is associated with increased psychological stress. Chronic psychological stress may have health effects in addition to those related to chemical exposures. Recommendation Health interventions that address chronic stress may have significant community benefits. These should be implemented before, or concurrent with, cleanup efforts. Conclusion 8 Children of aged 1-4 years are the group at highest risk for lead expo- sure. The committee found it inappropriate that the HHRA presented aggregate data on childhood lead screening for children aged 0-9 years of age. Children less than 1 year old are at very low risk for lead poisoning because of their relative lack of mobility. Likewise, hand-to-mouth activity falls dramatically at about 4 years of age. Children 5-9 years of age are less

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214 superfund and mining megasites likely to have elevated lead levels. Although in many cases the data in the HHRA were further stratified to 0-5 years and 6-9 years, there was an inex- plicable tendency to lump these age groups together. We strongly discourage such a practice because it is misleading and tends to underestimate the risk among the correct target group. REFERENCES AAP (American Academy of Pediatrics). 1995. Lead Screening Practices of Pediatricians. P ­ eriodic Survey of Fellows No. 28. Division of Health Policy Research, American Academy of Pediatrics. July 1995 [online]. Available: http://www.aap.org/research/periodic survey/ ps28exs.htm [accessed Feb. 4, 2005]. Aleksandrov, A.A., O.N. Polyakova, and A.S. Batuev. 2001. The effects of prenatal stress on learning in rats in a Morris maze. Neurosci. Behav. Physiol. 31(1):71-74. Aschengrau, A., A. Beiser, D. Bellinger, D. Copenhafer, and M. Weitzman. 1994. The impact of soil lead abatement on urban children’s BLLs: Phase II results from the Boston lead-In-Soil Demonstration Project. Environ. Res. 67(2):125-148. Aschengrau, A., A. Beiser, D. Bellinger, D. Copenhafer, and M. Weitzman. 1997. Residential lead-based-paint hazard remediation and soil lead abatement: Their impact among chil- dren with mildly elevated BLLs. Am. J. Public Health 87(10):1698-1702. ATSDR (Agency for Toxic Substances and Disease Registry). 1995. Public Health Assess- ment, National Zinc Company, Bartlesville, Washington County, OK. Cerclis No. OKD000829440. U.S. Department of Health and Human Services, Public Health Service, Agency for Toxic Substances and Disease Registry, Atlanta, GA. February 21, 1995 [on- line]. Available: http://www.atsdr.cdc.gov/HAC/PHA/zinc/nzc_toc.html [accessed Feb. 2, 2005]. ATSDR (Agency for Toxic Substances and Disease Registry). 2000. Coeur d’Alene River Basin Environmental Health Exposure Assessment, Final Report. U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry, Division of Health Studies, Atlanta, GA. ATSDR (Agency for Toxic Substances and Disease Registry). 2004a. Report To Congress; Tar Creek Superfund Site, Ottawa County, Oklahoma. Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry, Atlanta, GA [online]. Avail- able: http://www.atsdr.cdc.gov/sites/tarcreek/tarcreekreport-toc.html [accessed May 12, 2005]. ATSDR (Agency for Toxic Substances and Disease Registry). 2004b. Final Report: Follow-Up Study to Investigate BLLs in Children in Galena, Kansas. Kansas Department of Health and Environment, Topeka, KS. December 2004. Bates, M.N., A.H. Smith, and K.P. Cantor. 1995. Case-control study of bladder cancer and arsenic in drinking water. Am. J. Epidemiol. 141(6):523-530. Battelle. 1995. Review of Studies Addressing Lead Abatement Effectiveness. EPA 747-R-95- 006. Prepared by Battelle, Columbus, OH, for the Technical Programs Branch, Chemical Management Division, Office of Pollution Prevention and Toxics, U.S. Environmental Protection Agency, Washington, DC. July. Battelle. 1998. Review of Studies Addressing Lead Abatement Effectiveness: Updated Edition. EPA 747-B-98-001. Prepared by Battelle, Columbus, OH, for the Technical Programs Branch, Chemical Management Division, Office of Pollution Prevention and Toxics. U.S. Environmental Protection Agency, Washington, DC [online]. Available: http://www.epa. gov/lead/finalreport.pdf [accessed Feb. 3, 2005].

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