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This initiative is one example of efforts to better assess, characterize, and address relationships between environmental factors and health and to address the challenges of noninfectious agents and chronic diseases. Initiatives to assess environmental factors that contribute to health status require findings, data, and expertise from both the environmental protection and public health sectors 14, Integrated assessments use findings and data from different disciplines to generate more informative assessments relevant to public policy problems Integrated assessment methods relevant to climate change 17, 18, 19, 20 and integration of human and ecological risk assessment 21 have been developed.

Elements of these methods can be applied to environmental health. To communicate effectively to stakeholders and policy audiences requires development of understandable and interpretable ways to present data.

Protecting Children's Environmental Health: A Comprehensive Framework

Environmental health indicators are increasingly being used to summarize technical information and characterize key environmental factors, health outcomes, and relationships between them 22, 23, 24, 25, Such environmental health indicators can be distinguished from indicators that focus primarily on either the environment 27 or on health Environmental factors that affect children may differ from those most relevant to adults because children can be both more vulnerable and more highly exposed than adults 29, Lifelong consequences of exposures in early life are beginning to be observed 31, Efforts to assess children's environmental health systematically are beginning internationally 33, 34, 35, For example, the WHO in Europe has developed estimates of children's disease burden from air pollution, water and sanitation, lead, and injury Addressing children's health needs, including those associated with environmental factors, requires targeted approaches to information gathering and assessment In , we began to develop a set of measures relevant to children's environmental health in the United States.

Initial results were released in 38 , and an expanded assessment, titled America's Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses , was released in In this article, we report on the framework and methods used to develop this first integrated assessment of environment and health for children in the United States. The steps in the assessment of children's environmental health, shown in figure 1 , were to develop a framework to represent relationships between environmental factors and health; select topic areas; identify, assess, and select data sources and develop specific measures to represent the data; investigate surrogate measures when data were not available for a measure identified as most directly relevant; specify computational approaches or metrics and data elements to generate the measures and implement them; develop graphical representations of the measures; identify measures that are related; and identify data gaps and future directions for additional research and analysis.

Our working definition of the "environment" generally encompassed environmental factors or agents subject to management and regulatory attention by the U. EPA, the entity that sponsored the project. Use of this working definition represents a step in the development of an approach to assessment of children's environmental health.

It would also be appropriate to use a broader definition of the environment and include elements of the built environment or factors originating in sectors such as education, housing, or transportation.

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We convened workshops that included stakeholders and experts in toxicology, epidemiology, children's health, exposure assessment, and public health surveillance to discuss conceptual approaches, topics to be addressed, data sources, metrics, graphical representations, and data gaps. We consulted with technical and policy experts from key federal agencies. This analytic-deliberative process allowed us to meld the views of technical experts and stakeholders into a consistent approach and to identify the best available data sources and methods to address questions of interest.

Develop framework to depict the relationship between environment and health. We developed a framework to depict relationships between environmental factors and health. Driving forces include major social and economic changes and practices such as urbanization, poverty and inequality, scientific and technical advances, and patterns of production and consumption.

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Pressures include sources or releases of environmental agents. Environmental states include conditions of environmental media such as lakes or streams. Our framework, shown in figure 3 , includes driving forces; sources of releases of environment agents of concern; concentrations of environmental agents of concern measured or estimated in environmental ambient or exposure media; concentrations of agents of concern in human tissues; and health outcomes diseases and disorders in populations.

We included driving forces and sources of agents in the framework because control or elimination of sources is the policy strategy that reflects primary prevention. However, we did not develop measures for them because of resource limitations. We do not use the terms "pressures," "states," or "responses" because we have found them ambiguous.

Figure 3 shows types of information relevant to each component. Ambient environmental media include outdoor air, water, soil, or agricultural products; exposure media include outdoor air, indoor air, drinking water, food products, and dust. Concentrations in ambient media are often significant determinants of exposure. For example, epidemiologic studies have measured pollutant contaminants in ambient media and quantified relationships to health effects i. In this approach, we consider data about concentrations of environmental agents in exposure media and concentrations of agents of concern in human tissues.

Identify topic areas to address. The second step was to identify topic areas of interest. For environmental contaminants, these areas included outdoor air pollutants, indoor air pollutants, drinking water contaminants, contaminants in foods, and contaminants in soil. For contaminants in humans, we included topic areas identified as a concern in the environment and for children for which we could produce a meaningful interpretation of data available from the nationally representative sample developed by CDC For diseases and disorders, we included examples important to the health of children for which there was also published research that showed an established or suggested link to one or more environmental contaminants, based on previous analysis, consultation with experts, survey of the scientific literature, and use of standard references and existing reviews We reviewed emerging research on the links between air pollutants and respiratory outcomes in children and adults, evidence for environmental factors that contribute to cancer in children, and studies that examined links between environmental exposures and neurodevelopmental disorders We did not attempt at the outset to identify all topic areas that might be relevant; rather, we endeavored to identify a scope of work that could be accomplished with available resources.

We identified agents and outcomes of concern first and then sought data sources for these agents and outcomes to allow for identification of data gaps. Assess and select data sources and develop measures. For each topic area, we concurrently identified and assessed potential data sources and considered relevant ways to represent data. For each candidate data source, we assessed accessibility, validity and reliability, data elements, time period for which data were available, geographic area and resolution, and applicability to children.

We sought data sources with sufficient documentation, standard collection procedures, and quality assurance. We consulted key references and knowledgeable parties.


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When multiple sources were available, we selected the source with the best representation of the United States and best coverage of the study period. For some topic areas, we could not identify usable data sources. In conjunction with the review of data sources, we developed measures for the topic areas. We reviewed measures included in Healthy People In some cases, we concluded that more than one measure was needed. For example, for criteria air pollutants, we included one measure that reflected air quality on a daily basis, which is related to health effects associated with short-term, high concentrations of pollutants.

Because chronic exposures to lower concentrations of pollutants are also relevant, we included a measure based on annual concentrations for some pollutants. To reflect the coverage of data sources, we estimated the percent of the population represented. Investigate surrogates where data are not available. If a data source directly representative of a condition of interest was not available, we investigated surrogates that reflected related conditions. For example, we used reported violations of drinking water standards as a surrogate for concentrations of contaminants in drinking water.

We assessed data for surrogate measures using the same approach used for other sources. Specify computational approach and data elements and implement the measure. The sixth step was to devise the method to be used to compute or generate the measure, to select the metric, and to identify data elements to be used and their sources. Measures were then computed. Design graphical representation of the measure. Along with the computation of the measure, we selected an approach to present results graphically for each measure.

We considered how to show limitations, distributions, and coverage of the data. Identify related measures. To highlight relationships between contaminants and outcomes, we identified measures that were related. For example, measures that reflect concentrations of mercury in foods would be related to measures that reflect concentrations of mercury in blood of women of childbearing age. Table 1 shows measures that may be viewed as related.

This approach can identify additional areas for research, needs for further review or consideration of existing research, or areas in need of policy development or intervention. Identify data gaps. The last step was to describe data gaps. In some cases, we included a narrative description of the topic area as an emerging issue. Other topic areas were identified as data gaps. For even the best data sources, there are usually limitations on coverage or representativeness.

We addressed some of these issues in the final step. There are many important topics for children's environmental health with little or no coverage in the set of measures assembled. The analysis resulted in the development of measures for environmental contaminants, human body burdens, and diseases and disorders.

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Table 2 shows the full set of measures and their coverage. The development of measures raises numerous issues. One issue for environmental contaminant and body burden measures is whether a point of comparison should be used. Measured or estimated values can be compared to regulatory standards, such as ambient air quality standards, or other benchmarks.

Such comparisons can be useful because most people understand that concentrations that exceed such standards may be related to potential for disease.

Health Effects and Indoor Environmental Quality

However, regulatory standards may result from balancing of health with other factors, such as cost or technologic feasibility of control technologies. Such standards would not represent an appropriate point of comparison from a health perspective. Comparison to a fixed standard can create an impression that there is a "safe" concentration below which exposures would not pose any risk to health. However, for many pollutants, there may be no threshold, as is the case for particulate matter, ozone, and blood concentrations of lead 44, 45, 46, 47, 48, How to reflect the distribution of the data is important as well.

For example, for blood lead concentrations, the median or average value gives an idea of the typical child's exposure, but will not convey the potential magnitude of risk that could be experienced by children with concentrations at the higher end, such as the 95th percentile. It is useful to report both central and high-end estimates and to characterize groups likely to be affected by the higher exposures. This approach may be important for identifying health disparities or differences in exposures. The analysis identified numerous data gaps.

For criteria air pollutants, a significant gap is the geographic extent of the monitoring network.


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  4. Even when monitors are assigned by county, many counties have no data. This data gap might be rectified best by additional modeling. For hazardous air pollutants, the assessment was based on model predictions of ambient concentrations of a certain number of hazardous air pollutants. There are two structural limitations for this data source. One is that the modeling is done only every 3 years, and the results are presented several years after the year to which they apply.

    The second is that the approach includes only a relatively small number of pollutants. For indoor air pollutants, data do not exist on any large scale. Different approaches to assessing indoor air pollutants and indoor environments as a whole are needed. We believe that surrogate measures will be necessary for indoor pollutants.

    For drinking water contaminants, the national data reporting system has the significant limitation that violations, not measured concentrations, are reported. The latter would be more informative, but such data are available only at the state level. There are also significant limitations on monitoring and reporting. For food and land contaminants, the data available are very limited. Surrogates were needed in both categories.

    Substantial additional assessment would be needed to characterize these areas fully. For body burdens, the data available for most contaminants come from the recent monitoring programs developed by the CDC. Because this initiative is relatively new, the data are limited to only a few years. For diseases, surveys such as the National Health Interview Survey provides a good picture of the population as a whole, but it does not allow for breakout by geographic area or state.

    The information cannot be put on a common scale with other environmental data or information. For some important health outcomes, such as birth defects, there is no national data source that can be used. Data for neurodevelopmental effects are also very limited. What to include in an assessment is an important consideration.

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    The working definition of "the environment" used for these measures corresponded closely to the mandates of the U. It included environmental agents that can contaminate environmental media resulting in exposure. Such agents fall under regulatory mandates of the U. However, many other factors can be viewed as falling under the rubric of the environment. It may be more difficult to identify data sources if a more expansive definition of environmental factors is used in future work.

    Even with this relatively narrow scope, there are significant limits to our understanding of the links between environmental factors and health outcomes. In conducting an assessment that is geared to reporting progress and identifying areas in need of attention, it is important to consider probable contributors to disease and diseases that are likely caused at least partly by environmental factors, even when these relationships have not been fully established.

    It is helpful to look at available information in two ways. It is beneficial to look at toxicology and other experimental results, to see what can be learned about possible relationships of environmental factors to health outcomes or related biologic effects. Measuring Progress. Market and Consumer Research. Clean Cooking Catalog. Demand Creation. Supply Strengthening. HOME Resources. Majid Ezzati, Daniel M. Topic: Health Country: Global.

    Globally, almost 3 billion people rely on biomass wood, charcoal, crop residues, and dung and coal as their primary source of domestic energy. Exposure to indoor air pollution IAP from the combustion of solid fuels is an important cause of morbidity and mortality in developing countries. In this paper, we review the current knowledge on the relationship between IAP exposure and disease and on interventions for reducing exposure and disease. We take an environmental health perspective and consider the details of both exposure and health effects that are needed for successful intervention strategies.

    We also identify knowledge gaps and detailed research questions that are essential in successful design and dissemination of preventive measures and policies.